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Introduction: Continuous glucose monitoring (CGM) provides detailed information about glucose level fluctuations over time. The method is increasingly being used in pregnant women with type 1 diabetes. However, only one previous study compared CGM results related to pregnancy outcomes in women using insulin pumps with those administering multiple daily injections (MDI). We performed a secondary analysis of CGM metrics from an observational cohort of pregnant women with type 1 diabetes and compared insulin pump and MDI therapies in relation to maternal and neonatal outcomes. Material and methods: The study included 185 pregnant Swedish women with type 1 diabetes undergoing CGM throughout pregnancy. Women were divided according to insulin administration mode, ie MDI (n = 131) or pump (n = 54). A total of 91 women used real-time CGM and 94 women used intermittently viewed CGM. Maternal demographics and maternal and neonatal outcome data were collected from medical records. CGM data were analyzed according to predefined glycemic indices: mean glucose; standard deviation; percentage of time within, below and above glucose target range; mean amplitude of glycemic excursion; high and low glucose indices; and coefficient variation in percent. Associations between insulin administration mode and CGM data, on the one hand, and maternal and neonatal outcomes, on the other, were analyzed with analysis of covariance and logistic regression, respectively, adjusted for confounders. Results: There were no differences in maternal characteristics or glycemic indices between the MDI and pump groups, except for a longer duration of type 1 diabetes and higher frequencies of microangiopathy and real-time CGM among pump users. Despite improvement with each trimester, glucose levels remained suboptimal throughout pregnancy in both groups. There were no differences between the MDI and pump groups concerning the respective associations with any of the outcomes. The frequency of large for gestational age was high in both groups (MDI 49% vs pump 63%) and did not differ significantly. Conclusions: Pregnant women with type 1 diabetes did not differ in glycemic control or pregnancy outcome, related to MDI or pump administration of insulin. Glycemic control remained suboptimal throughout pregnancy, regardless of insulin administration mode. (Less)

Mucosal linings of the body, including the conjunctiva, are enriched in tissue-resident memory T cells (TRMs) whose defining feature is their continual tissue protection that does not rely on migration to lymphoid organs to elicit immune responses. Hitherto, conjunctival TRMs have only been identified in the superficial epithelium. This work aims to develop a more complete understanding of the conjunctival immunological capacity by investigating the presence of TRMs within the deeper, more stable layers of the healthy human conjunctiva. Using immunofluorescence microscopy and antibodies against CD3, CD4, CD69 and HLA-DR on bulbar conjunctival biopsies obtained from 7 healthy adults (age range = 32–77 years; females = 4), we identified CD69+TRM subsets in all layers of the human conjunctiva: the superficial epithelium, the basal epithelium, the adenoid, and the fibrous layers. Interestingly, the adenoid layer showed significantly higher densities of both CD4 and CD8 TRMs when compared to the fibrous layer and conjunctival epithelia. Additionally, CD4 TRMs predominated significantly over CD8 TRMs in the adenoid layer. The abundance of deep conjunctival CD69+TRMs within the healthy human may suggest the presence of defence mechanisms capable of inducing long-term immunogenic memory. Understanding this spatial distribution of conjunctival CD69+TRMs is essential to improving mucosal vaccine design.

Objective: This systematic review aimed to evaluate the nature of interventions addressing eating psychopathology in athletes, identify the characteristics of successful interventions, and review the efficacy of interventions at reducing or preventing eating psychopathology. Method: SPORTDiscus, MEDLINE and PsycINFO were searched to identify studies addressing eating psychopathology in athletes, which included an outcome measure of disordered eating. Results: Seventeen studies (11 randomised controlled trials, 6 non randomised trials) reporting data on 13 interventions were included. The methodological quality was observed to be generally low. All interventions (11 implemented in North America) were delivered face-to-face in groups with variable duration and intensity. Thirteen studies reported significant reductions in athletes’ eating psychopathology following the intervention, with seven reporting sustained effects (small-to-moderate). Successful interventions were characterised by higher intervention dosage, higher retention, and incorporated a focus on self-esteem and self-efficacy. Conclusion: The complex nature of interventions, combined with a lack of evaluation data and poor methodological quality, limits the scaling and refinement of many interventions. Future research should explore other modes of delivery, collect evaluation data, and adhere to clearer study reporting. Doing this will consequently improve the development and delivery of effective eating psychopathology interventions offered to athletes more widely.

The ERBB2 gene encodes a receptor tyrosine kinase also known as HER2. The gene is amplified and overexpressed in one-fifth of breast carcinomas; patients with such tumors benefit from targeted treatment with trastuzumab or other drugs blocking the receptor. In addition, ERBB2 has been shown to be amplified and/or overexpressed in a variety of other malignancies. Notably, both alveolar and embryonal rhabdomyosarcoma (RMS), especially in children, often show increased expression of ERBB2. Although high-level amplification of the gene has not been described in RMS, its frequent expression at the cell surface of RMS cells has been exploited for chimeric antigen receptor T-cell (CAR T)-based treatment strategies. We here describe two cases of pediatric, fusion-negative embryonal RMS with high-level amplification of the ERBB2 gene. One patient is currently treated with conventional chemotherapy for a recently detected standard risk RMS, whereas the other patient died from metastatic disease. Both tumors displayed focal amplicons (210 and 274 Kb, respectively) in chromosome band 17q12, with proximal and distal borders corresponding to those typically seen in breast cancer. In both tumors, the ERBB2 amplicon correlated with high expression at the RNA and protein levels. Thus, breast cancer-like ERBB2 amplification is a very rare, but recurrent feature of pediatric RMS, and should be exploited as an alternative treatment target. Funding Agencies|Governmental Funding of Clinical Research within the National Health Service of Sweden; Swedish Cancer SocietySwedish Cancer Society; Swedish Childhood Cancer Fund

Objectives To investigate the effect of catheter ablation (CA) on symptoms and health-related quality of life (HRQoL) after 5 years, and analyze predictors of recurrence of symptoms. Background The primary indication for CA of atrial fibrillation (AF) is to reduce symptoms and improve HRQoL where long-term follow-up are sparse. Methods In this observational, long-term, single-center study, patients were recruited from Linkoping University Hospital, Sweden. They were aged >= 18 years and had been referred for CA from November 2011 until June 2019. Arrhythmia-specific symptoms and HRQoL were assessed by patient-reported outcome measures (PROMs) with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA). Results In the study were 1521 patients, 69% men, mean age 62 years. At baseline, 87% of the patients and at the 5-year follow-up 80% of those eligible filled out the ASTA questionnaire. At follow-up, 50% reported freedom from symptoms, 18% had >50% symptom reduction, 14% had a minor reduction, while 18% reported no effect or a worsening of symptoms. Factors predicting symptoms were female gender (hazard ratio [HR]: 1.8; 1.2-2.8), body mass index >= 35 (HR: 3.9; 1.6-9.8), and ischemic heart disease (IHD) (HR: 2.6; 1.2-5.9). After 5 years, breathlessness during activity, weakness/fatigue, and tiredness were still the most common symptoms; regarding HRQoL they were impaired physical ability and deteriorated life situation. Conclusions and Clinical Implications This clinical cohort of patients with AF evaluated through PROMs showed that CA had long-lasting effects on symptoms and HRQoL and that the use of PROMs in clinical routines was feasible. Factors predicting symptoms after CA were female gender, IHD, and obesity, an important reminder to encourage lifestyle management.

Acceptance of animal research by the public depends on several characteristics of the specific experimental study. In particular, acceptance decreases as potential animal pain or distress increases. Our objective in this study was to quantify the magnitude of pain/distress that university undergraduate students and faculty would find to be justifiable in animal research, and to see how that justifiability varied according to the purpose of the research, or the species to which the animal belonged. We also evaluate how demographic characteristics of respondents may be associated with their opinions about justifiability. To accomplish this goal, we developed and administered a survey to students and faculty at the University of Wisconsin-Madison. Our survey employed Likert-style questions that asked them to designate the level of animal pain or distress that they felt was justifiable for each of the following six purposes—animal disease, human disease, basic research, human medicine, chemical testing, or cosmetic testing. These questions were asked about five different species of animals including monkeys, dogs/cats, pig/sheep, rats/mice, or small fish. We used the data to establish a purpose-specific pain/distress scale, a species-specific pain/distress scale, and a composite pain/distress scale that, for each respondent, averaged the extent of justifiable pain/distress across all purposes and species. For purpose, students were more likely to choose higher levels of pain for animal disease research, followed by human disease, basic research, human medicine, chemical testing, and cosmetic testing. Faculty were more likely to choose the same level of pain for the first four purposes, followed by lower levels of pain for chemical and cosmetic testing. For species, students were more likely to choose higher levels of pain for small fish and rats/mice (tied), pigs/sheep and monkeys (tied), than for dogs/cats. For faculty, order from least to most justifiable pain/distress was small fish, rats/mice, pigs/sheep, then dogs/cats and monkeys (the latter two tied). Interestingly, exploratory factor analysis of the pain/distress scales indicated that when it comes to justifying higher levels of pain and distress, respondents identified two distinct categories of purposes, chemical and cosmetic testing, for which respondents were less likely to justify higher levels of pain or distress as compared to other purposes; and two distinct categories of species, small fish and rats/mice, for which respondents were more likely to justify higher levels of pain/distress than other species. We found that the spread of acceptance of animal research was much smaller when survey questions included pain/distress compared to when only purpose or species were part of the question. Demographically, women, vegetarians/vegans, and respondents with no experience in animal research justified less animal pain/distress than their counterparts. Not surprisingly, a lower level of support for animal research in general was correlated with lower justifiability of pain/distress. Based on these findings, we discuss the role of animal pain/distress in regulatory considerations underlying decisions about whether to approve specific animal uses, and suggest ways to strengthen the ethical review and public acceptance of animal research.

The conceptualisation and measurement of the associations between narcissism and muscle dysmorphia (MD) are poorly understood in the literature. It is recognised that narcissism features two broad dimensions: vulnerable and grandiose. Studying both narcissism dimensions is important given their differences in etiology and health-related outcomes. Therefore, the aim of this study was to investigate the associations between MD, vulnerable and grandiose narcissism. A total of 336 participants (48% male; Mage = 26.4 years) completed measures of MD and narcissism. Hierarchical regression analysis revealed that vulnerable narcissism was significantly, positively associated with MD, whilst grandiose narcissism was not. Practitioners should be aware that vulnerable narcissism may be a potential risk factor of MD.

Purpose: Children's results on school-related achievements tests, such as aspects of math, reading and writing, have been shown to decline following a lengthy summer vacation. Few studies have investigated whether this also applies to vocabulary skills. The purpose of this study is to investigate how lexical organization and retrieval, assessed by a semantic verbal fluency (SVF) task, develops during a lengthy summer vacation versus formal schooling.Method: Sixty-eight children with mean age of 7.9 (ranging from 6.5 to 9.1), were assessed pre- and post-summer vacation and post-fall semester using two SVF categories (Animals and Clothes). The number of words produced in both categories gave the total score.Results: The result of the SVF tests decreased following summer vacation. The loss was recouped at the post-fall semester assessment, but no gains compared to initial testing were shown. Neither level of parental education, general language ability, non-verbal IQ, nor bilingualism explained the variance in development during the summer vacation or the fall semester.Conclusions: Our findings indicate that a lengthy summer vacation causes a recess in the expected development of SVF ability and that this recess is recouped after a semester of formal schooling. The findings are in line with previous research indicating that summer vacation may have negative impact on the development of important scholastic abilities in children.

Preeclampsia is a hypertensive disorder of pregnancy associated with vascular dysfunction and cardiovascular risk to offspring. We hypothesize that endothelial PPARγ (peroxisome proliferator–activated receptor-γ) provides cardiovascular protection in offspring from pregnancies complicated by hypertension. C57BL/6J dams were bred with E-V290M sires, which express a dominant-negative allele of PPARγ selectively in the endothelium. Arginine vasopressin was infused throughout gestation. Vasopressin elevated maternal blood pressure at gestational day 14 to 15 and urinary protein at day 17 consistent. Systolic blood pressure and vasodilation responses to acetylcholine were similar in vasopressin-exposed offspring compared to offspring from control pregnancies. We treated offspring with a subpressor dose of angiotensin II to test if hypertension during pregnancy predisposes offspring to hypertension. Male and female angiotensin II–treated E-V290M offspring from vasopressin-exposed but not control pregnancy exhibited significant impairment in acetylcholine-induced relaxation in carotid artery. Endothelial dysfunction in angiotensin II–treated E-V290M vasopressin-exposed offspring was attenuated by tempol, an effect which was more prominent in male offspring. Nrf2 (nuclear factor-E2-related factor) protein levels were significantly elevated in aorta from male E-V290M offspring, but not female offspring compared to controls. Blockade of ROCK (Rho-kinase) signaling and incubation with a ROCK2-specific inhibitor improved endothelial function in both male and female E-V290M offspring from vasopressin-exposed pregnancy. Our data suggest that interference with endothelial PPARγ in offspring from vasopressin-exposed pregnancies increases the risk for endothelial dysfunction on exposure to a cardiovascular stressor in adulthood. This implies that endothelial PPARγ provides protection to cardiovascular stressors in offspring of a pregnancy complicated by hypertension and perhaps in preeclampsia.

Background: How patients preserve their sense of dignity in life is an important area of palliative care that remains to be explored. Aims: To describe patients' perspectives of what constitutes a dignified life within a palliative care context. Methods: Twelve palliative care patients were interviewed about their views on living with dignity. Data were analysed using qualitative content analysis. Results: What constitutes a dignified life during end-of-life care was captured by the theme ‘I may be ill but I am still a human being’ and presented under the categories ‘preserving my everyday life and personhood’, ‘having my human value maintained by others through ‘coherence’ and ‘being supported by society at large’. Conclusion: Patients' sense of dignity can be preserved by their own attitudes and behaviours, by others and through public support. Health professionals need to adopt a dignity-conserving approach, for which awareness of their own attitudes and behaviours is crucial.

Milk quality and clinical mastitis in dairy cows are monitored by detecting visually abnormal milk. A standardized method to evaluate clots in milk and studies of the incidence and dynamics of clots in milk at the quarter level are lacking. We validated a method to score clot density in quarter milk samples and describe the prevalence and dynamics of the density scores between consecutive samplings and periods in 4 farms with automatic milking systems. Using in-line filters, we collected quarter milk samples at each milking during 3 periods of 30 h each in each farm. Clot density was scored based on coverage of the filter area as 0 (negative), 1 (trace), 2 (mild), 3 (moderate), 4 (heavy), and 5 (very heavy). The score for a specific quarter and milking is referred to as the quarter milking score (QMS). Three assessors independently scored 902 images of filter samples with a Fleiss kappa value of 0.72. In total, 21,202 quarter milk samples from 5,398 milkings of 621 cows were collected. Of the quarter filter samples, 2.4% had visible clots, distributed as mild (1.4%), moderate (0.6%), heavy (0.3%), and very heavy (1 in the following milking, with an average chance of 38%. The probability of a QMS > 1 increased with increasing previous QMS, a higher sum of QMS during the milking period, longer milking interval, and higher lactation number, but decreased with increasing days in milk. Our study showed that the method of clot-density scoring is feasible to perform and reproducible for investigating the occurrence and dynamics of clots in milk. Elevated clot-density scores clustered within certain cows and cow periods and appeared in new quarters of the cows over time. The low recurrence of QMS of 1 and 2 within quarters indicated that QMS 3 could be a reasonable threshold for detecting quarters with abnormal milk that require further attention.

Preeclampsia is a severe gestational hypertensive condition linked to child neuropsychiatric disorders, although underlying mechanisms are unclear. We used a recently developed, clinically relevant animal model of preeclampsia to assess offspring. C57BL/6J mouse dams were chronically infused with arginine vasopressin (AVP) or saline (24 ng/h) throughout pregnancy. Adult offspring were behaviorally tested (Y-maze, open field, rotarod, social approach, and elevated plus maze). Offspring brain was assessed histologically and by RNA sequencing. Preeclampsia-exposed adult males exhibited increased anxiety-like behavior and social approach while adult females exhibited impaired procedural learning. Adult AVP-exposed males had reduced total neocortical volume. Adult AVP-exposed females had increased caudate–putamen volume, increased caudate–putamen cell number, and decreased excitatory synapse density in hippocampal dentate gyrus (DG), CA1, and CA3. At postnatal day 7 (P7), AVP-exposed male and female offspring both had smaller neocortex. At P7, AVP-exposed males also had smaller caudate–putamen volume, while females had increased caudate–putamen volume relative to neocortical size. Similar to P7, E18 AVP-exposed offspring had smaller dorsal forebrain, mainly in reduced intermediate, subventricular, and ventricular zone volume, particularly in males. Decreased volume was not accounted for by cell size or cerebrovascular vessel diameter changes. E18 cortical RNAseq revealed 49 differentially-expressed genes in male AVP-exposed offspring, over-representing cytoplasmic translation processes. In females, 31 genes were differentially-expressed, over-representing collagen-related and epithelial regulation pathways. Gene expression changes in E18 AVP-exposed placenta indicated potential underlying mechanisms. Deficits in behavior and forebrain development in this AVP-based preeclampsia model were distinctly different in males and females, implicating different neurobiological bases.

Background Patients can form antibodies to foreign human leukocyte antigen (HLA) Class I antigens after exposure to allogeneic cells. These anti-HLA class I antibodies can bind transfused platelets (PLTs) and mediate their destruction, thus leading to PLT refractoriness. Patients with PLT refractoriness need HLA-matched PLTs, which require expensive HLA typing of donors, antibody analyses of patient sera and/or crossmatching. An alternative approach is to reduce PLT HLA Class I expression using a brief incubation in citric acid on ice at low pH. Methods and materials Apheresis PLT concentrates were depleted of HLA Class I complexes by 5 minutes incubation in ice-cold citric acid, at pH 3.0. Surface expression of HLA Class I complexes, CD62P, CD63, phosphatidylserine, and complement factor C3c was analyzed by flow cytometry. PLT functionality was tested by thromboelastography (TEG). Results Acid treatment reduced the expression of HLA Class I complexes by 71% and potential for C3c binding by 11.5-fold compared to untreated PLTs. Acid-treated PLTs were significantly more activated than untreated PLTs, but irrespective of this increase in steady-state activation, CD62P and CD63 were strongly upregulated on both acid-treated and untreated PLTs after stimulation with thrombin receptor agonist peptide. Acid treatment did not induce apoptosis over time. X-ray irradiation did not significantly influence the expression of HLA Class I complexes, CD62P, CD63, and TEG variables on acid treated PLTs. Conclusion The relatively simple acid stripping method can be used with irradiated apheresis PLTs and may prevent transfusion-associated HLA sensitization and overcome PLT refractoriness.

Objective: To compare outcomes after treatment with autologous haematopoietic stem cell transplantation (AHSCT) and alemtuzumab (ALZ) in patients with relapsing-remitting multiple sclerosis. Methods: Patients treated with AHSCT (n=69) received a conditioning regimen of cyclophosphamide (200 mg/ kg) and rabbit anti-thymocyte globulinerG (6.0 mg/kg). Patients treated with ALZ (n=75) received a dose of 60 mg over 5 days, a repeated dose of 36 mg over 3 days after 1 year and then as needed. Follow-up visits with assessment of the expanded disability status scale score, adverse events and MR investigations were made at least yearly. Results: The Kaplan-Meier estimates of the primary outcome measure 'no evidence of disease activity' was 88% for AHSCT and 37% for ALZ at 3 years, p

To ensure milk quality and detect cows with signs of mastitis, visual inspection of milk by prestripping quarters before milking is recommended in many countries. An objective method to find milk changed in homogeneity (i.e., with clots) is to use commercially available inline filters to inspect the milk. Due to the required manual labor, this method is not applicable in automatic milking systems (AMS). We investigated the possibility of detecting and predicting changes in milk homogeneity using data generated by AMS. In total, 21,335 quarter-level milk inspections were performed on 5,424 milkings of 624 unique cows on 4 farms by applying visual inspection of inline filters that assembled clots from the separate quarters during milking. Images of the filters with clots were scored for density, resulting in 892 observations with signs of clots for analysis (77% traces or mild cases, 15% moderate cases, and 8% heavy cases). The quarter density scores were combined into 1 score indicating the presence of clots during a single cow milking and into 2 scores summarizing the density scores in cow milkings during a 30-h sampling period. Data generated from the AMS, such as milk yield, milk flow, conductivity, and online somatic cell counts, were used as input to 4 multilayer perceptron models to detect or predict single milkings with clots and to detect milking periods with clots. All models resulted in high specificity (98–100%), showing that the models correctly classified cow milkings or cow milking periods with no clots observed. The ability to successfully classify cow milkings or cow periods with observed clots had a low sensitivity. The highest sensitivity (26%) was obtained by the model that detected clots in a single milking. The prevalence of clots in the data was low (2.4%), which was reflected in the results. The positive predictive value depends on the prevalence and was relatively high, with the highest positive predictive value (72%) reached in the model that detected clots during the 30-h sampling periods. The misclassification rate for cow milkings that included higher-density scores was lower, indicating that the models that detected or predicted clots in a single milking could better distinguish the heavier cases of clots. Using data from AMS to detect and predict changes in milk homogeneity seems to be possible, although the prediction performance for the definitions of clots used in this study was poor.

Background The impact of hearing loss on the individual and his/her everyday life can be assessed using questionnaires with the purpose to improve rehabilitation quality. The Abbreviated Profile of Hearing Aid Benefit (APHAB) can be used to evaluate disability in everyday life associated with hearing loss. Previous studies have examined APHAB outcomes in sensorineural hearing loss and we do not know whether the type of hearing loss influence questionnaire outcomes. Purpose The purpose was to evaluate the psychometric properties of a Swedish translation of the APHAB and the influence of demographic variables on the outcome in a clinical sample. Research Design A descriptive, cross-sectional study in a clinical sample. Study Sample Forty-eight participants with no hearing aid experience seeking audiological rehabilitation for the first time. These participants represented different degrees of hearing loss and three types of hearing loss: monaural mixed, binaural mixed, and binaural sensorineural hearing loss. Data Collection and Analysis Pure-tone audiometry was conducted and the participants completed the unaided APHAB during their first appointment at the clinic. Psychometric properties of the questionnaire were examined and the influence of age, gender, type of hearing loss, and degree of hearing loss on APHAB scores were studied. Results The psychometric properties indicate high test-retest reliability but there seems to be some potential issues with the properties of the reverberation (RV) subscale. The items from the RV subscale failed to load as a separate component and the internal consistency of the subscale improved by removing four items (items 1, 9, 11, and 16). With few exceptions, APHAB scores were not influenced by age, gender, or type of hearing loss. APHAB scores were generally influenced by degree of hearing loss in both the best and the worst ear. Conclusion This Swedish version of the APHAB can be additionally improved by addressing the inconsistencies found in the RV subscale by rephrasing or removing some items. The degree of hearing loss has some influence on questionnaire outcomes but not age, gender, and type of hearing loss.

Preeclampsia complicates 5% to 8% of all pregnancies. Previous studies have examined the maternal morbidity and mortality associated with preeclampsia and the expectant management of severe preterm preeclampsia. However, these studies either did not comment on outcomes by race or were primarily made up of nonblack participants.This study aimed to determine whether maternal morbidity associated with the expectant management of severe preterm preeclampsia varied by race.We performed a retrospective cohort study of women with a diagnosis of severe preterm preeclampsia at34 weeks' gestation between 2008 and 2017 at our institution. Severe preterm preeclampsia was defined by current American College of Obstetricians and Gynecologists guidelines. The primary outcome was a maternal morbidity composite, defined as experiencing ≥1 of the following: hemolysis, elevated liver enzymes, and low platelet count; eclampsia; pulmonary edema; severe renal dysfunction; abruption; maternal intensive care unit admission; venous thromboembolism; blood transfusion; hysterectomy; stroke; or death. Secondary outcomes included a composite of neonatal morbidity. Outcomes were compared between self-reported black and nonblack women.In this study, 275 women were included; among those women, 91 (33%) were nonblack, and 184 (67%) were black. In addition, 203 of 275 women (approximately 74%) underwent expectant management with no difference by race (75.8% of nonblack vs 72.8% of black women; P=.6). When examining maternal morbidity, 62 of the expectantly managed women (30.5%) developed the composite maternal morbidity outcome, with no difference by race (27.5% of nonblack vs 32.1% of black women; P=.5) even when adjusting for confounders such as maternal age, body mass index, and parity (adjusted odds ratio, 1.02; 95% confidence interval, 0.97-1.35). The median time from diagnosis to delivery (latency time) was 3 days, with no difference between the 2 groups (P=.9) and no difference in neonatal morbidity (60.9% nonblack vs 53% black; P=.3).Within our population, there were no differences in maternal outcomes between black and nonblack women who were undergoing expectant management of severe preterm preeclampsia. More research is needed to determine if the known disparities in maternal morbidity among races are due to factors beyond the antepartum management of severe preterm preeclampsia.

Background Being next-of-kin to someone with cancer requiring palliative care involves a complex life situation. Changes in roles and relationships might occur and the next-of-kin thereby try to adapt by being involved in the ill person’s experiences and care even though they can feel unprepared for the care they are expected to provide. Therefore, the aim of this study was to develop a classic grounded theory of next-of-kin in palliative cancer care. Method Forty-two next-of-kin to persons with cancer in palliative phase or persons who had died from cancer were interviewed. Theoretical sampling was used during data collection. The data was analysed using classic Grounded Theory methodology to conceptualize patterns of human behaviour. Results Constructing stability emerged as the pattern of behaviour through which next-of-kin deal with their main concern; struggling with helplessness. This helplessness includes an involuntary waiting for the inevitable. The waiting causes sadness and frustration, which in turn increases the helplessness. The theory involves; Shielding, Acknowledging the reality, Going all in, Putting up boundaries, Asking for help, and Planning for the inescapable. These strategies can be used separately or simultaneously and they can also overlap each other. There are several conditions that may impact the theory Constructing stability, which strategies are used, and what the outcomes might be. Some conditions that emerged in this theory are time, personal finances, attitudes from extended family and friends and availability of healthcare resources. Conclusions The theory shows the complexities of being next-of-kin to someone receiving palliative care, while striving to construct stability. This theory can increase healthcare professionals’ awareness of how next-of-kin struggle with helplessness and thus generates insight into how to support them in this struggle.

BackgroundThe significance of metaphors for the experience of cancer has been the topic of extensive previous research, with “Battle” and “Journey” metaphors standing out as key. Adaptation to the patient’s use of metaphor is generally believed to be an important aspect of person-centered care, especially in palliative care. The aim of this study was to investigate the use of metaphors in blogs written in Swedish by people living with advanced cancer and explore possible patterns associated with individuals, age and gender.MethodsThe study is based on a dataset totaling 2,602,479 words produced some time during the period 2007–2016 by 27 individuals diagnosed with advanced cancer. Both qualitative and quantitative procedures were used, and the findings are represented as raw frequencies as well as normalized frequencies per 10,000 words. Our general approach was exploratory and descriptive. The Mann-Whitney U test was used to analyze statistical significance.ResultsOur results confirm the strong foothold of “Journey” and “Battle” metaphors. “Imprisonment” and “Burden” metaphors were also used by the majority of the individuals. The propensity to use metaphors when describing the cancer experience was found to differ extensively across the individuals. However, individuals were not found to opt for one conceptualization over the other but tended to draw on several different metaphor domains when conceptualizing their experience. Socio-demographic factors such as age or gender were not found to be strong predictors of metaphor choice in this limited study.ConclusionsUsing a range of different metaphors allows individuals with advanced cancer to highlight different aspects of their experience. The presence of metaphors associated with “Journey”, “Battle”, “Imprisonment” and “Burden” across individuals could be explained by the fact that the bloggers are part of a culturally consistent cohort, despite variations in age, sex and cancer form. Awareness of metaphors commonly used by patients can enhance health professionals’ capacity to identify metaphorical patterns and develop a common language grounded in the patients’ own metaphor use, which is an important requisite for person-centered palliative care.

Background The aim of this study was to optimize a Question Prompt List which is designed to improve communication about the heart failure trajectory among patients, family members, and health care professionals. Methods Data were collected in a two-round Delphi survey and a cross-sectional survey, including patients with heart failure, their family members, and health care professionals working in heart failure care in Sweden and the Netherlands. Acceptability for and demand of the Question Prompt List were assessed. Results A total of 96 patients, 63 family members and 26 health care professionals participated in the study. Regarding acceptability, most of the original questions were found to be relevant by the participants for inclusion in the Question Prompt List but some cultural differences exist, which resulted in two versions of the list: a Swedish version including 33 questions and a Dutch version including 38 questions. Concerning demand, participants reported that they were interested in discussing the questions in the revised Question Prompt List with a physician or a nurse. Few patients and family members reported that they were worried by the questions in the Question Prompt List and hence did not want to discuss the questions. Conclusions This Question Prompt List has successfully been adapted into a Swedish version and a Dutch version and includes questions about the HF trajectory which patients, their families, and health care professionals perceived to be relevant for discussion in clinical practice. Overall, patients and family members were not worried about the content in the Question Prompt List and if used in accordance with patients’ and family members’ preferences, the Question Prompt List can help to improve communication about the heart failure trajectory.

One of the most common and reliable ways of monitoring udder health and milk quality in dairy herds is by monthly cow composite somatic cell counts (CMSCC). However, such sampling can be time consuming, and more automated sampling tools entail extra costs. Machine learning methods for prediction have been widely investigated in mastitis detection research, and CMSCC is normally used as a predictor or gold standard in such models. Predicted CMSCC between samplings could supply important information and be used as an input for udder health decision-support tools. To our knowledge, methods to predict CMSCC are lacking. Our aim was to find a method to predict CMSCC by using regularly recorded quarter milk data such as milk flow or conductivity. The milk data were collected at the quarter level for 8 wk when milking 372 Holstein-Friesian cows, resulting in a data set of 30,734 records with information on 87 variables. The cows were milked in an automatic milking rotary and sampled once weekly to obtain CMSCC values. The machine learning methods chosen for evaluation were the generalized additive model (GAM), random forest, and multilayer perceptron (MLP). For each method, 4 models with different predictor variable setups were evaluated: models based on 7-d lagged or 3-d lagged records before the CMSCC sampling and additionally for each setup but removing cow number as a predictor variable (which captures indirect information regarding cows' overall level of CMSCC based on previous samplings). The methods were evaluated by a 5-fold cross validation and predictions on future data using models with the 4 different variable setups. The results indicated that GAM was the superior model, although MLP was equally good when fewer data were used. Information regarding the cows' level of previous CMSCC was shown to be important for prediction, lowering prediction error in both GAM and MLP. We conclude that the use of GAM or MLP for CMSCC prediction is promising.

As members of a university community that sponsors animal research, we developed a survey to improve our knowledge about factors underlying the perceived justifiability of animal research among faculty and undergraduate students. To accomplish this objective, we gathered quantitative data about their general views on animal use by humans, their specific views about the use of different species to address different categories of scientific questions, and their confidence in the translatability of animal research to humans. Students and faculty did not differ in their reported levels of concern for the human use of animals, but women reported significantly higher levels of concern than men. Among students, experience with animal research was positively correlated with less concern with animal use, and having practiced vegetarianism or veganism was associated with more concern. Gender, experience with animal research, and dietary preferences were similarly correlated with the extent of justifiability of animal use across all research purposes and species. Faculty responses resembled those for students, with the exception that justifiability varied significantly based on academic discipline: biological sciences faculty were least concerned about human use of animals and most supportive of animal research regardless of purpose or species. For both students and faculty, justifiability varied depending on research purpose or animal species. Research purposes, ranked in order of justifiability from high to low, was animal disease, human disease, basic research, human medicine, animal production, chemical testing, and cosmetics. Justifiability by purpose was slightly lower for students than for faculty. Species justifiability for students, from high to low, was small fish, rats or mice, pigs or sheep, monkeys, and dogs or cats. Faculty order was the same except that monkeys and dogs or cats were reversed in order. Finally, confidence in the translatability of animal research to our understanding of human biology and medicine was not different between students and faculty or between genders, but among faculty it was highest in biological sciences followed by physical sciences, social sciences, and then arts and humanities. Those with experience in animal research displayed the most confidence, and vegetarians/vegans displayed the least. These findings demonstrate that, although the range of views in any subcategory is large, views about animal research justifiability can vary significantly among respondent subpopulations in predictable ways. In particular, research purpose and choice of animal species are important variables for many people. This supports the claim that ensuring purpose and species are robustly integrated into research proposal reviews and approvals should be considered to be a best practice. We suggest that strengthening this integration beyond what is described in current regulations would better meet the justifiability criteria expressed by members of our campus community.

Aggregation and deposition of misfolded amyloid-β (Aβ) peptide in the brain is central to Alzheimer's disease (AD). Oligomeric, protofibrillar, and fibrillar forms of Aβ are believed to be neurotoxic and cause neurodegeneration in AD, but the toxicity mechanisms are not well understood and may involve Aβ-interacting molecular partners. In a previous study, we identified potential Aβ42 protofibrillar-binding proteins in serum and cerebrospinal fluid (CSF) using an engineered version of Aβ42 (Aβ42CC) that forms protofibrils, but not fibrils. Here we studied binding of proteins to Aβ42 fibrils in AD and non-AD CSF and compared these with protofibrillar Aβ42CC-binding partners. Aβ42 fibrils sequestered 2.4-fold more proteins than Aβ42CC protofibrils. Proteins with selective binding to fibrillar aggregates with low nanomolar affinity were identified. We also found that protofibrillar and fibrillar Aβ-binding proteins represent distinct functional categories. Aβ42CC protofibrils triggered interactions with proteins involved in catalytic activities, like transferases and oxidoreductases, while Aβ42 fibrils were more likely involved in binding to proteoglycans, growth factors and neuron-associated proteins, e.g., neurexin-1, -2, and -3. Interestingly, 10 brain-enriched proteins were identified among the fibril-binding proteins, while protofibril-extracted proteins had more general expression patterns. Both types of Aβ aggregates bound several extracellular proteins. Additionally, we list a set of CSF proteins that might have potential to discriminate between AD and non-AD CSF samples. The results may be of relevance both for biomarker studies and for studies of Aβ-related toxicity mechanisms.

Background: Behavioral testing provides an essential approach in further developing our understanding of brain structure and function. The aim of our study was to outline a more expanded approach to cognition- and anxiety related behavior in the rabbit. Methods: Twenty-one 70-day old rabbits (13 female, 8 male) were exposed to open field test, dark-light box test and object recognition testing with variations in inter-trial-interval, olfactory recognition and object location testing. Independent T-tests were used to compare data by individual baseline characteristics, i.e. birth weight, weight at testing, sex, litter #, litter size. Results: In the open field test, median time spent in the center was 3.64 s (0.84-41.36) for the 9 rabbits who entered the center; median distance moved in the arena was 874.42 cm (54.20-3444.83). In the dark light box test, 12 rabbits entered the light compartment. In the object recognition task, rabbits spent significantly less time exploring the familiar object compared to the novel (0.40 s [0-2.8] vs. 3.17 s [1.30-32.69]; P = 0.003) when using a 30-min inter-trial interval, as well with a 90-min inter-trial interval: 0.87 s [0-7.8] vs. 7.65 s [0-37.6] (P = 0.008). However, recognition was lost when using a 24-h inter-trial interval (time spent exploring the familiar object: 3.33 [0-10.90]; novel object :3.87 [1.15-48.53]; n.s). In the object location task and in olfactory object recognition task, median discrimination indexes were 0.69 (-1 to 1) and 0.37 (-0.38 to 0.78) respectively, higher than level expected by chance (P < 0.001). Litter size > 3 during the neonatal period was associated with increased explorative behavior in the dark light box test (P = 0.046) and in the visual object recognition task (P = 0.005), whereas body weight and sex were not. Conclusions: Settings and outcome measures for multiple behavioral tests, providing reference values and considerations for future developmental studies are reported. Discrimination and memory in the rabbit appear to relate to litter characteristics, although a larger sample size is needed to confirm our findings.

Background Despite increased attention and knowledge in palliative care, there is still confusion concerning how to interpret the concept of palliative care and implement it in practice. This can result in difficulties for healthcare professionals in identifying patients whom would benefit from palliative care, which, in turn, could lead to a delay in meeting patients' needs. Aim To explore healthcare professionals' perceptions of palliative care. Method Data were collected through twelve interprofessional focus group interviews in community care and hospital wards in south Sweden (n = 74). All interviews were analysed with latent content analysis. Results Three domains were revealed: first, a blurred conceptual understanding as participants described palliative care using synonyms, diagnoses, phases, natural care and holism; second, a challenge to communicate transitions concerned the importance of how and when the transition to palliative care was communicated and documented; finally, a need for interprofessional collaboration was described as well as the consequences for severely ill persons, relatives and healthcare professionals when it was not established. Conclusion The perceptions about how to interpret palliative care differed as well as when palliative care should be offered and decided, which might have practical consequences. How long a person has left to live is of great significance for decision-making, caregiving and preparation in palliative care. The challenge is to use interprofessional communication to promote understanding and collaborate across varied care levels. Integrating palliative care across diverse care levels could be one way to reduce the ambiguity of palliative care.

The pathogenesis of preeclampsia, a hypertensive disorder of pregnancy, involves imbalanced T helper (TH) cell populations and resultant changes in pro- and anti-inflammatory cytokine release. Elevated copeptin (an inert biomarker of arginine vasopressin (AVP)), secretion precedes the development of symptoms in preeclampsia in humans, and infusion of AVP proximal to and throughout gestation is sufficient to initiate cardiovascular and renal phenotypes of preeclampsia in wild-type C57BL/6J mice. We hypothesize that AVP infusion in wild-type mice is sufficient to induce the immune changes observed in human preeclampsia. AVP infusion throughout gestation in mice resulted in increased pro-inflammatory interferon gamma (IFNg) (TH1) in the maternal plasma. The TH17-associated cytokine IL-17 was elevated in the maternal plasma, amniotic fluid, and placenta following AVP infusion. Conversely, the TH2-associated anti-inflammatory cytokine interleukin (IL)-4 was decreased in the maternal and fetal kidneys from AVP-infused dams while IL-10 was decreased in the maternal kidney and all fetal tissues. Collectively, these results demonstrate the sufficiency of AVP to induce the immune changes typical of preeclampsia. We investigated if T cells can respond directly to AVP by evaluating the expression of AVP receptors (AVPRs) on mouse and human CD4+ T cells. Mouse and human T cells expressed AVPR1a, AVPR1b, and AVPR2. The expression of AVPR1a was decreased in CD4+ T cells obtained from preeclampsia-affected women. In total, our data are consistent with a potential initiating role for AVP in the immune dysfunction typical of preeclampsia and identifies putative signaling mechanism(s) for future investigation.

Purpose The aims of this study were to describe and compare diagnoses, symptoms, and care needs in palliative cancer patients in two medium-sized hospitals in a county council with no specialized palliative care available 24/7; to analyze the relationships between diagnosis and symptoms/care needs; and to compare results and trends from two datasets (from 2007 and 2012). Methods The study was population-based with a cross-sectional design and was conducted at two acute care hospitals. We performed 142 one-day inventories (n = 2972) in 2007 and 139 in 2012 (n = 2843) to register symptoms, care needs, and diagnosis based on a questionnaire. Multiple logistic regression models were used in the analysis. Results During 2007 and 2012 combined, 10% (n = 589) of hospitalized patients were assessed as having cancer in a palliative phase. Prostate (12%) and colorectal (12%) cancers were most common. Pain (42%) and deterioration (42%) were the most prevalent symptoms and were associated with pancreas cancer in our regression models (p = 0.003 and p = 0.019, respectively). Other cancers had different associations: hematologic malignancies were associated with infections and blood transfusions (p

Leptin contributes to the control of resting metabolic rate (RMR) and blood pressure (BP) through its actions in the arcuate nucleus (ARC). The renin-angiotensin system (RAS) and angiotensin AT1 receptors within the brain are also involved in the control of RMR and BP, but whether this regulation overlaps with leptin's actions is unclear. Here, we have demonstrated the selective requirement of the AT1A receptor in leptin-mediated control of RMR. We observed that AT1A receptors colocalized with leptin receptors (LEPRs) in the ARC. Cellular coexpression of AT1A and LEPR was almost exclusive to the ARC and occurred primarily within neurons expressing agouti-related peptide (AgRP). Mice lacking the AT1A receptor specifically in LEPR-expressing cells failed to show an increase in RMR in response to a high-fat diet and deoxycorticosterone acetate-salt (DOCA-salt) treatments, but BP control remained intact. Accordingly, loss of RMR control was recapitulated in mice lacking AT1A in AgRP-expressing cells. We conclude that angiotensin activates divergent mechanisms to control BP and RMR and that the brain RAS functions as a major integrator for RMR control through its actions at leptin-sensitive AgRP cells of the ARC.

Background: In Sweden, FreeStyle Libre a flash glucose monitoring system came onto the market in 2014 as a complement to self-monitoring of blood glucose. The aim of this study was to evaluate the accuracy and treatment experience of the FreeStyle Libre system. Methods: Fifty-eight adults with type 1 diabetes used FreeStyle Libre for 10–14 days and measured capillary blood glucose levels with the HemoCue blood glucose measurement system at least six times a day simultaneously. Results: For the entire study period, the mean absolute relative difference (MARD) was 13.2% (95% confidence interval [CI] 12.0%–14.4%). MARD was 13.6% (95% CI 12.1%–15.4%) during week 1 and 12.7% (95% CI 11.5%–13.9%) during week 2. The mean absolute difference (MAD) for the whole study period was 19.8 mg/dL (1.1 mmol/L) (95% CI 17.8–21.8 mg/dL), including 20.5 mg/dL (1.14 mmol/L) during week 1 and 19.0 mg/dL (1.05 mmol/L) during week 2. The overall correlation coefficient was 0.96. For glucose values 180 mg/dL (10 mmol/L), the MARD was 20.3% (95% CI 17.7%–23.1%), 14.7% (95% CI 13.4%–16%), and 9.6% (95% CI 8.5%–10.8%), respectively, and respective MAD values were 12.3, 17.8, and 23.6 mg/dL (0.69, 0.99, and 1.31 mmol/L). Using the 10-item visual analog scale, patients rated their experience with FreeStyle Libre as generally positive, with mean values ranging from 8.22 to 9.8. Conclusions: FreeStyle Libre had a similar overall MARD as continuous blood glucose monitoring systems in earlier studies when studied in similar at-home conditions. The overall patient satisfaction was high.

It is well known that people with severe mental illness have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as metabolic syndrome, cardiovascular disease and type 2 diabetes. There are still, however, only a few published studies focusing on what enables healthy living for this group. This study thus aimed to describe what enables healthy living among people with severe mental illness in psychiatric outpatient services. The data were collected in qualitative interviews (n = 16) and content analysis was used to analyze the data. The interviews resulted in an overall theme "Being regarded as a whole human being by self and others", which showed the multidimensional nature of health and the issues that enable healthy living among people with severe mental illness. Three categories emerged: (i) everyday structure (ii), motivating life events and (iii) support from significant others. The results indicate that a person with severe mental illness needs to be encountered as a whole person if healthy living is to be enabled. Attaining healthy living requires collaboration between the providers of care, help and support. Health care organizations need to work together to develop and provide interventions to enable healthy living and to reduce poor physical health among people with severe mental illness.

Cascade-specific termination of G protein signaling is catalyzed by the RGS (regulator of G protein signaling) family members, including RGS2 . Angiotensin, vasopressin, and endothelin are implicated in preeclampsia, and RGS2 is known to inhibit G protein cascades activated by these hormones. Mutations in RGS2 are associated with human hypertension and increased risk of developing preeclampsia and its sequelae. RGS family members are known to influence maternal vascular function, but the role of RGS2 within the placenta has not been explored. Here, we hypothesized that reduced expression of RGS2 within the placenta represents a risk factor for the development of preeclampsia. Although cAMP/CREB signaling was enriched in placentas from human pregnancies affected by preeclampsia compared with clinically matched controls and RGS2 is known to be a CREB-responsive gene, RGS2 mRNA was reduced in placentas from pregnancies affected by preeclampsia. Experimentally reducing Rgs2 expression within the feto-placental unit was sufficient to induce preeclampsia-like phenotypes in pregnant wild-type C57BL/6J mice. Stimulation of RGS2 transcription within immortalized human HTR8/SVneo trophoblasts by cAMP/CREB signaling was discovered to be dependent on the activity of histone deacetylase activity, and more specifically, HDAC9 (histone deacetylase-9), and HDAC9 expression was reduced in placentas from human pregnancies affected by preeclampsia. We conclude that reduced expression of RGS2 within the placenta may mechanistically contribute to preeclampsia. More generally, this work identifies RGS2 as an HDAC9 -dependent CREB-responsive gene, which may contribute to reduced RGS2 expression in placenta during preeclampsia.

PurposeTo evaluate residency applicant (RA) and residency program director (RPD) perceptions of Phase II of the Match process since its inception in 2016.MethodsAn online survey was issued to all Match-registered RAs and RPDs for the 2016, 2017, and 2018 Match periods. Study participant demographics, participant designation (RA or RPD), the year(s) and Phase(s) of the Match participated in were measured using categorical ranges, and overall perceptions of the Match process since Phase II of the Match was implemented were captured with 5-point Likert scales.ResultsA total of 2,599 individuals (RA and RPD) completed the survey for an overall survey response rate of 12.6%. The majority of RAs were female (73.2%), under the age of 30 (87.4%), Caucasian (67.4%), and recently graduated (90.9% graduated between 2016 and 2018). Most RAs participated in the 2018 Match period (61%), and overall 82% successfully matched to a residency position. RA perceptions relating to process cost-effectiveness and perceived fairness to all applicants differed significantly from RPD perceptions (2.23 versus 3.71 and 2.80 versus 3.67, respectively; p < 0.001 for each). There were no differences between RA and RPD perceptions related to the submission/review process.ConclusionThe Phase II of the Match process has demonstrated improved organization and satisfaction from the RPD perspective compared to the previous process. RAs have identified several areas for improvement in the process. It is imperative that efforts are made to continue expanding program and position offerings as much as possible.

Neurodegeneration in multiple sclerosis (MS) correlates with disease progression and reparative processes may be triggered. Growth-associated protein 43 (GAP-43) exhibits induced expression during axonal growth and reduced expression during MS progression. We aimed to evaluate if GAP-43 can serve as a biomarker of regeneration in relapsing-remitting MS (RRMS) and whether disease-modifying therapies (DMTs) influence GAP-43 concentration in cerebrospinal fluid (CSF). GAP-43 was measured using an enzyme-linked immunosorbent assay in 105 MS patients (73 RRMS, 12 primary progressive MS, 20 secondary progressive MS) and 23 healthy controls (HCs). In 35 of the patients, lumbar puncture, clinical assessment, and magnetic resonance imaging was performed before initiation of therapeutic intervention, and at follow-up. CSF GAP-43 concentration was significantly lower in progressive MS compared with HCs (p = 0.004) and RRMS (p = p = 0.026). However, DMTs did not alter CSF GAP-43. Interestingly, in RRMS CSF GAP-43 levels were higher in patients with signs of active inflammatory disease than in patients in remission (p = 0.042). According to CSF GAP-43 concentrations, regeneration seems reduced in progressive MS, increased during disease activity in RRMS but is unaffected by treatment of highly active DMTs.

ObjectivesFor patients’ entire families, it can be challenging to live with cancer during the palliative stage. However, a sense of coherence buffers stress and could help health professionals identify families that require support. Therefore, the short version of the Family Sense of Coherence Scale (FSOC-S) was translated, culturally adapted, and validated in a Swedish sample.MethodsTranslation and cross-cultural adaptation of the FSOC-S into Swedish was conducted in accordance with the World Health Organization's Process for Translation and Adaptation of Research Instruments guidelines. Participants were recruited from two oncology clinics and two palliative centers in Sweden.ResultsContent validity was supported by experts (n = 7), persons with cancer (n = 179), and family members (n = 165). Homogeneity among items was satisfactory for persons with cancer and family members (item-total correlations were 0.45‒0.70 and 0.55‒0.72, respectively) as well as internal consistency (ordinal alpha = 0.91 and 0.91, respectively). Factor analyses supported unidimensionality. FSOC-S correlated (rs > 0.3) with hope, anxiety, and symptoms of depression, which supported convergent validity. The test-retest reliability for items ranged between fair and good (kw = 0.37‒0.61).Significance of ResultsThe FSOC-S has satisfactory measurement properties to assess family sense of coherence in persons with cancer and their family members. FSOC-S could be used to identify family members who experience low levels of perceived family sense of coherence which provides health care professionals with insight into families’ needs and ability to live with cancer in the palliative stage.

Background: There is evidence indicating that family sense of coherence predicts quality of family life and promotes family well-being. In families living with the palliative phase of cancer, low hope, anxiety and symptoms of depression are common in both persons with cancer and their family members. Aim: To determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression, respectively, in persons with cancer in the palliative phase and their family members. Design: An observational, cross-sectional, multicentre study was conducted. Nested linear regression analyses were performed in two blocks to determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression. Setting/participants: Persons with cancer ( n = 179) and their family members ( n = 165) were recruited from two oncology clinics and two palliative centres in three regions in Sweden. Results: The main findings showed that family sense of coherence was significantly and independently associated with hope, anxiety and symptoms of depression. Stronger family sense of coherence was associated with higher hope and lower anxiety and symptoms of depression levels in both persons with cancer and their family members. Conclusion: Health care providers should strive to identify families with weak family sense of coherence, because of its associations with hope, anxiety and symptoms of depression, in order to offer them professional support and thereby achieve increased well-being during the palliative phase of cancer. Future studies should expand our knowledge of family sense of coherence and how to identify families at risk of lower levels of well-being.

Background: There is currently little evidence regarding the use of medical cannabis for the treatment of intractable pain. Literature published on the subject to date has yielded mixed results concerning the efficacy of medical cannabis and has been limited by study design and regulatory issues. Objective: The objective of this study was to determine if the use of medical cannabis affects the amount of opioids and benzodiazepines used by patients on a daily basis. Methods: This single-center, retrospective cohort study evaluated opioid and benzodiazepine doses over a 6-month time period for patients certified to use medical cannabis for intractable pain. All available daily milligram morphine equivalents (MMEs) and daily diazepam equivalents (DEs) were calculated at baseline and at 3 and 6 months. Results: A total of 77 patients were included in the final analysis. There was a statistically significant decrease in median MME from baseline to 3 months (−32.5 mg; P = 0.013) and 6 months (−39.1 mg; P = 0.001). Additionally, there was a non–statistically significant decrease in median DE at 3 months (−3.75 mg; P = 0.285) and no change in median DE from baseline to 6 months (−0 mg; P = 0.833). Conclusion and Relevance: Over the course of this 6-month retrospective study, patients using medical cannabis for intractable pain experienced a significant reduction in the number of MMEs available to use for pain control. No significant difference was noted in DE from baseline. Further prospective studies are warranted to confirm or deny the opioid-sparing effects of medical cannabis when used to treat intractable pain.

Living with a life-limiting cancer illness can entail a turmoil of feelings such as constant fear of loss, suffering and dying. Because patients live longer with life-limiting illness, there is a need for enhanced understanding of how people make sense of and cope with the complicated aspects that this life situation brings on. In this article, we explore how bloggers with advanced cancer use metaphors as ways of making sense of their experiences. Our study is theoretically grounded in Conceptual Metaphor Theory, where metaphors are seen as a powerful phenomenon that both reflects and affects our thinking. The data consist of a corpus of blogs written in Swedish by individuals with advanced cancer, and the findings from our linguistic metaphor analysis are consistently interpreted against the backdrop of literature on coping. Our study thus highlights the intersection of linguistic metaphor analysis and psychological theories of coping by illustrating the many and complex functions metaphors can have as part of sense-making processes. Our hermeneutic approach enables us to show some differences among the three most pervasive metaphor domains in our material, battle, journey and imprisonment: the journey and imprisonment domains are more flexible than the battle domain in terms of the different kinds of coping strategies that are actualised by the bloggers’ use of metaphors. One particular finding from our analysis is the way in which the bloggers make use of metaphors to compartmentalise experiences and emotions. Our contention is that careful attention to the metaphors used by patients can improve communication in healthcare and enhance understanding of the complex role language use plays in coping processes more generally. By highlighting the relation between metaphor use and coping, our analysis also provides a way to discuss coping strategies based on the patient’s own use of language.

People with psychotic disorders experience to a great extent avoidable physical illnesses and early mortality. The aim of the study was to investigate the potential effects for this group of participating in a lifestyle intervention. A multi-component nurse-led lifestyle intervention using quasi-experimental design was performed. Changes in biomedical and clinical measurements, self-reported health, symptoms of illness and health behavior were investigated. Multilevel modeling was used to statistically test differences in changes over time. Statistically significant changes were found in physical activity, HbA1c and waist circumference. A lifestyle intervention for people with severe mental illness can be beneficial for increasing physical activity. © 2019 Blomqvist et al. Published with license by Taylor & Francis Group, LLC. Funders: Regional Council for Medical Health Care Research, County of Halland, Sweden and the Regional Council for Medical Health Care Research, County of Kronoberg, Sweden.

Individual behavior affects and is affected by other people. The aim of this study was to examine if emotional distress in patients with atrial fibrillation (AF) and their spouses was associated with their own and their partner’s perceived health. Participants included 91 dyads of patients and their spouses. Emotional distress was measured using the Hospital Anxiety and Depression Scale and perceived health was measured with the Short Form 36 Health Survey. The Actor–Partner Interdependence Model was used for dyad-level analyses of associations, using structural equation modeling. Higher levels of anxiety and depression were associated with lower levels of perceived health in patients and spouses. Higher levels of depression in patients were associated with lower levels of vitality in spouses and vice versa. As AF patients and their spouses influence each other, health-care interventions should consider the dyad to address dyadic dynamics. This may benefit the health of the individual patient and of the couple.

The aim of this study was to develop a grounded theory about people with psychiatric disabilities, living in supported housing. Interviews as well as observations during the interviews were analyzed together with secondary analyses of quantitative and qualitative material from previous studies. Being deprived of self-determination emerged as the main concern for residents in supported housing and striving for meaning emerged as the pattern of behavior through which this group resolves their main concern. Striving for meaning involves living in the present, striving for self-determination, strengthening self-esteem, emotional processing and resting from the present. The strategies facilitate each other and are used singly, together simultaneously, or alternately. If they are successful, a meaning in the present is perceived. If all the strategies fail repeatedly, escaping from the present is used in order to deal with being deprived of self-determination. The implications of the findings suggest prioritizing a reduction of the institutional nature of the social and physical environment, and to support the residents’ self-determination. Key words: Grounded theory, psychiatric disabilities, self-determination, supported housing (Published: 10 May 2016) Citation: Int J Qualitative Stud Health Well-being 2016, 11: 31249 - http://dx.doi.org/10.3402/qhw.v11.31249

Copeptin, a marker of arginine vasopressin (AVP) secretion, is elevated throughout human pregnancies complicated by preeclampsia (PE), and AVP infusion throughout gestation is sufficient to induce the major phenotypes of PE in mice. Thus, we hypothesized a role for AVP in the pathogenesis of PE. AVP infusion into pregnant C57BL/6J mice resulted in hypertension, renal glomerular endotheliosis, intrauterine growth restriction, decreased placental growth factor (PGF), altered placental morphology, placental oxidative stress, and placental gene expression consistent with human PE. Interestingly, these changes occurred despite a lack of placental hypoxia or elevations in placental fms-like tyrosine kinase-1 (FLT1). Coinfusion of AVP receptor antagonists and time-restricted infusion of AVP uncovered a mid-gestational role for the AVPR1A receptor in the observed renal pathologies, versus mid- and late-gestational roles for the AVPR2 receptor in the blood pressure and fetal phenotypes. These findings demonstrate that AVP is sufficient to initiate phenotypes of PE in the absence of placental hypoxia, and indicate that AVP may mechanistically (independently, and possibly synergistically with hypoxia) contribute to the development of clinical signs of PE in specific subtypes of human PE. Additionally, they identify divergent and gestational time-specific signaling mechanisms that mediate the development of PE phenotypes in response to AVP.

Resistivity index (RI) of the pericallosal artery as is commonly measured during head ultrasound (US) examination in neonates. Some studies have shown that RI measured with gentle compression of the fontanelle provides additional information in cases of neonatal brain anomalies. The purpose of this study was to establish normal RI values with and without compression in a large population of neonates with normal cranial ultrasound as a function of gestational age. The authors of this retrospective study reviewed the RI of 323 infants with normal gray-scale cranial US and with a gestational age ranging 26–42 weeks. We conducted the exams both with and without compression of the anterior fontanelle and we studied changes in RI depending on gestational age, gender and type of delivery. Infants with a gestational age of more than 35 weeks tended to have a lower RI (P=0.011). The compression of the anterior fontanelle emphasized the change in RI with increasing gestational age, with higher gestational ages having a lower RI (P

Providing palliative care involves serious challenges for nurses, such as end-of-life decisions, contact with people's suffering and dying, and increased risk of burnout. However, studies have revealed that the burnout level of health professionals working in palliative care is lower than that of health professionals working in other settings. This study aimed to describe the lived experiences of nurses caring in a palliative care unit. A phenomenological descriptive study was undertaken. Nine nurses were recruited from a palliative care unit in Portugal. Data were collected using individual interviews and analyzed following the method of Giorgi. Five themes reflect the essence of the lived experience: (1) experience centered on the relationship with the other (ie, the patient and the family), (2) experience centered on the relationship with one's own self, (3) exhausting experience, (4) rewarding experience, and (5) the team as a pillar. These findings can be valuable for understanding the challenges and strategies experienced by nurses caring in palliative care and for designing interventions that focus on reducing the risk of burnout among nurses-not only those working in palliative care but also those working in other contexts who experience regular contact with suffering and death.

Guided imagery (GI) is a nonpharmacological intervention that is increasingly implemented in different clinical contexts. However, there have been no studies on the effect of GI on the comfort of inpatients of palliative care (PC) units. Therefore, the aim of this study was to evaluate the effects of GI on the comfort of patients in PC. A 1-group, pretest-posttest, pre-experimental design was used to measure differences in heart rate, respiratory rate, pain, and comfort in patients (n = 26) before and after a 2-session GI program. The intervention featuring GI increased comfort, measured by an Abbreviated Holistic Comfort Scale and the visual analog comfort scale (P < .001), and decreased heart rate (P < .001), respiratory rate (P < .001), and pain, as measured by the (numerical) visual analog pain scale (P < .001). This study demonstrates that the use of an intervention featuring GI increases the comfort of oncology patients admitted to a PC unit. The use of GI by nurses is inexpensive, straightforward to implement, and readily available and may result in the provision of comfort care.

Background Nursing home residents in Sweden are old, frail and usually have multiple morbidities which often make dying a prolonged suffering. It has been found that older persons at nursing homes receive far less palliative care than younger persons, partly because it is difficult to identify when the final stage of life begins. The identification may help the staff to enable the older person and their families to participate in planning the care in accordance with their own preferences and values. With this in mind the aim was to explore the experiences of early and late signs preceding dying in older persons in nursing homes from the multidisciplinary team’s perspective. Methods The focus group method was used to interview 20 health-care professionals on the basis of semi-structured questions. Four focus groups were conducted at four nursing homes in two counties in southern Sweden. The groups included different professionals such as assistant nurses, registered nurses, occupational therapists, physiotherapists, social workers and unit managers. The analysis was conducted according to the focus group method developed by Kruger and Casey. Results The analysis revealed one major theme, from unawareness to obviousness, which illustrates that the participants experienced dying as a happening, not a process, and found it difficult to identify early signs. Even though it was a new way of thinking, several suggestions of early signs were presented. The main category “Going into a bubble” illustrates early signs, which meant that the older person showed signs of wanting to withdraw from the outside world. The main category “The body begins to shut down” illustrates late signs, which meant that the older person showed signs that indicate that the body starts to prepare for death. Conclusions This study conveys new knowledge concerning the multidisciplinary team’s collective experience of early and late signs that precede dying. This knowledge can increase the understanding of when a palliative care approach needs to be in place at nursing homes. The use of a palliative care approach in care planning requires consensus in the perception of the dying process of frail older persons.

BACKGROUND Silent atrial fibrillation (AF) episodes are common but the role of anticoagulation treatment is under debate. METHODS Consecutive patients with dual-chamber pacemakers for sinus node disease or AV block/bundle branch block were retrospectively enrolled and the development of silent AF, any anticoagulation and the incidence of ischaemic stroke and dementia were recorded. RESULTS In total 411 patients without and 267 with known AF at implant were included. During a median follow-up of 38 months, 30% (125/411) of patients without known AF at implant were diagnosed with silent AF, 62% of those had or were prescribed anticoagulation. Heart failure (p = 0.03) and age >75 years (p = 0.0002) were risk markers for incident silent AF. In patients with known AF at implant, 80% (216/267) were on anticoagulation at implant. The annual stroke incidence was 2.1% in patients with known AF at implant, as compared to 1.9% in patients who developed silent AF during follow-up, and 1.4% in patients without AF. Vascular dementia developed in 11.2% and 6.2% respectively in patients with known AF versus no AF (p = 0.048) as well as in 5.6% of those with silent AF (p = 0.09). CONCLUSION The stroke risk in our study population with an incident silent AF diagnosis may have been significantly decreased by the high proportion of anticoagulation treatment. This could imply that without this treatment the stroke risk might have been high enough to justify anticoagulation. Development of vascular dementia was twice as common among patients with known AF as compared to those witht silent AF or no AF. More data is needed to inform the optimal treatment for these patients.

The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care.This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients' postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time.Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher's exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes.Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.

Life expectancy is greatly reduced in patients with schizophrenia, and cardiovascular diseases are a leading cause of mortality. The aim of this cross-sectional study was to investigate the prevalence of overweight, obesity, and cardiovascular disease (CVD) risk and to investigate the relationships between self-rated health, sense of coherence, CVD risk, and body mass index (BMI) among people with severe mental illness (SMI) in psychiatric outpatient settings. Nearly 50% of the participants were exposed to moderate/high risk of CVD and over 50% were obese. The results showed no statistically relationships between the subjective and objective measures (Bayes factor

Background: The aim of this paper was to describe the development of an intervention that is developed to improve communication about the heart failure (HF) trajectory and end-of-life care. We also present data that provides a first insight in specific areas of feasibility of the intervention. Methods: Co-design was used and patients, family members and health care professionals were constructive participants in the design process of the intervention. Feasibility of the intervention was tested in two areas; acceptability and limited efficacy. Results: Two communication tools were designed and evaluated; 1) a Question Prompt List (QPL) for patients and family members and 2) a communication course for professionals which was web -based with one face-to-face training day with simulation. Data on feasibility was collected with questionnaires that were developed for this study, from the 13 participants who completed the course (all nurses). They reported improved knowledge, confidence and skills to discuss the HF trajectory and end-of-life care. The QPL was evaluated to be a useful tool in communication with patients and family members. Conclusions: In a co-design process, future users identified the need for a QPL and a communication course. These communication tools can be used as a dual intervention to improve communication about the HF trajectory and end-of-life care. The QPL can help patients and families to ask questions about the HF trajectory and end-of-life care. The communication course can prepare the professionals to be knowledgeable, confident and skilled to discuss the questions in the QPL. Before the tools are ready for implementation in clinical practice, further studies testing the feasibility of the intervention are needed, including also patients and their families. Funding Agencies|Medical Research Council of South east of Sweden [FORSS-645591]; Research and scholarship management in Region Ostergotland [LIO-656941]

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