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Serious mental illnesses (SMIs) exert a considerable financial burden on health-care systems. In this study, the resource utilization in mental illness (RUMI) tool was developed and employed to evaluate resource utilization in patients with SMI.Data from 107 patients with SMI treated in four psychiatric outpatient clinics in Sweden were collected. The relationships between costs for physical and psychiatric care, social services, and the justice system, to self-reported health and quality of life, educational level, Global Assessment of Functioning (GAF), the Clinical Global Impressions scale score (CGI), and body mass index (BMI) were studied.Sixteen out of 107 patients accounted for 74% of the total costs. The mean and median cost for 6 months included in the survey for social services, family and social welfare and healthcare, psychiatric and physical treatment interventions, mean 8349 EUR, median 2599 EUR per patient (currency value for 2021). Education and psychosocial function (GAF) were both negatively correlated with costs for the social services (education,The RUMI scale was acceptable and enabled estimation of resource utilization in a comparable manner across different care settings. Such comparable data have potential to provide a basis for budgeting and resource allocation.

Purpose To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR. Methods Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005–2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR. Results A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m2, time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28–0.58; P P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04–2.34; P = 0.03). Conclusion Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR. Level of evidence Level III.

To determine the association between a delay in anterior cruciate ligament reconstruction (ACLR), age, sex, body mass index (BMI) and cartilage injuries, meniscus injuries, meniscus repair, and abnormal prereconstruction laxity.Patients who underwent primary ACLR at our institution from January 2005 to March 2017, with no associated ligament injuries, were identified. Logistic regression analyses were used to evaluate whether delay in ACLR, age, sex, and BMI were risk factors for cartilage and meniscus injuries, meniscus repair, and abnormal (side-to-side difference5 mm) prereconstruction laxity.A total of 3976 patients (mean age 28.6 ± 10.6 years, range 10-61 years) were included. The risk of cartilage injury increased with a delay in ACLR (12-24 months: odds ratio [OR] 1.20; 95% confidence interval [CI] 1.05-1.29; P = .005; and24 months: OR 1.20; 95% CI 1.11-1.30; P.001) and age ≥30 years (OR 2.27; 95% CI 1.98-2.60; P.001). The risk of medial meniscus (MM) injury increased with a delay in ACLR (12-24 months: OR 1.20; 95% CI 1.07-1.29; P = .001; and24 months: OR 1.22; 95% CI 1.13-1.30; P.001), male sex (OR 1.16; 95% CI 1.04-1.30; P = .04) and age ≥30 years (OR 1.20; 95% CI 1.04-1.33; P = .008). The risk of lateral meniscus (LM) injury decreased with a delay in ACLR of3 months and age ≥30 years (OR 0.75; 95% CI 0.66-0.85; P .001), whereas it increased with male sex (OR 1.32; 95% CI 1.22-1.41; P.001). MM repairs relative to MM injury decreased with a delay in ACLR (6-12 months: OR 0.70; 95% CI 0.54-0.92; P = .01; 12-24 months: OR 0.69; 95% CI 0.57-0.85; P.001;24 months: OR 0.61; 95% CI 0.52-0.72; P.001) and age ≥30 years (OR 0.60; 95% CI 0.48-0.74; P .001). LM repairs relative to LM injury only decreased with age ≥30 years (OR 0.34; 95% CI 0.26-0.45; P.001). The risk of having abnormal knee laxity increased with a delay in ACLR of6 months and MM injury (OR 1.52; 95% CI 1.16-1.97; P = .002), whereas it decreased with a BMI of ≥25 (OR 0.68; 95% CI 0.52-0.89; P = .006).A delay in ACLR of12 months increased the risk of cartilage and MM injuries, whereas a delay of6 months increased the risk of abnormal prereconstruction laxity and reduced the likelihood of MM repair. To reduce meniscus loss and the risk of jeopardizing knee laxity, ACLR should be performed within 6 months after the injury.Level III, retrospective therapeutic comparative study.

Background:Early functional mobilization (EFM) may improve patient outcome after Achilles tendon rupture (ATR). However, whether EFM affects patient outcome via changes in tendon elongation, thickening, or calf muscle atrophy is unknown.Purpose:To analyze differences in tendon and muscle morphology recovery over time between groups treated with EFM or standard treatment after ATR repair.Study Design:Cohort study; Level of evidence, 2.Methods:This prospective cohort study included 86 patients (20 women) with ATR repair who had a mean (SD) age of 39.3 (8.2) years and were part of a larger prospective randomized controlled trial. Patients were postoperatively randomized to immediate postoperative weightbearing and ankle motion (EFM group) or to immobilization in a below-knee plaster cast for 2 weeks (control group). Patient-reported and functional outcomes were assessed at 6 and 12 months with the Achilles Tendon Total Rupture Score and the heel-rise test for endurance. At 2 and 6 weeks and 6 and 12 months postoperatively, B-mode ultrasound imaging was performed to assess the length and cross-sectional area (CSA) of the Achilles tendon, the gastrocnemius CSA, as well as the thickness of soleus.Results:The Achilles Tendon Total Rupture Score for the EFM and control groups were 65.8 (18.7) and 56.8 (20.1; P = .045), respectively, at 6 months and 79.6 (15.8) and 78.9 (17.2; P = .87), respectively, at 12 months. At 2 weeks, tendon elongation was significantly more pronounced in the EFM group as compared with the control group (mean side-to-side difference, 1.88 cm vs 0.71 cm; P = .005). Subsequently, tendon elongation increased in the control group while it decreased in the EFM group so that at 6 and 12 months no significant differences between groups were found. Mean Achilles tendon elongation at 1 year was 1.73 (1.07) cm for the EFM group (n = 55) and 1.67 (0.92) cm for the control group (n = 27), with a mean difference of 0.06 cm (95% CI, 0.54 to –0.42; P = .80). Achilles tendon CSA and calf muscle atrophy displayed no significant differences between the groups; however, significant changes were demonstrated over time ( P ≤ .001) in both groups.Conclusion:EFM results in more Achilles tendon elongation at early healing, but this difference subsides over time. EFM does not seem to affect patient outcome via changes in tendon elongation, thickening, or calf muscle atrophy.Registration:NCT02318472 (ClinicalTrials.gov identifier).

Context: The physical and mental demands of an elite football player are complex, which may explain why injuries are common in football. At elite level, muscle injuries of the lower-extremity are the most common among male football players, and the research hitherto is limited. Objective: To investigate whether personality traits affect the incidence of muscle injuries among male football players from the first league in Sweden. Design: Prospective cohort study. Participants: A male football team from the first league in Sweden was prospectively followed, in terms of muscle injuries of the lower-extremity during 8 seasons, between 2007 and 2015. Intervention: All muscle injuries included in this study were evaluated and diagnosed with ultrasonography. Players from the team filled out the Swedish Universities Scales of Personality questionnaire. Swedish Universities Scales of Personality questionnaire consists of 91 items and is divided into 13 categories. Main Outcome Measures: The raw values of each scale were linearly transformed to T scores, having a mean (SD) of 50 (10). All variables were summarized with standard descriptive statistics, such as frequency, mean, and SD. As data were of interval scale and no variable distribution was severely skewed, differences between noninjured players, rarely injured players, and frequently injured players were analyzed with 1-way analysis of variance with post hoc tests by Tukey honestly significant difference test. Results: No significant difference in personality traits were observed between noninjured players, rarely injured players, and frequently injured players regarding number of muscle injuries (P > .05). However, a trend (P = .07) was seen, where frequently injured players scored higher on stress susceptibility than rarely injured players. Conclusion: A player’s stress susceptibility should be taken into consideration by the player, coaches, and medical staff when assessing the risk of a muscle injury. Also, preventive measures available for these players may need to be considered.

Purpose To analyse the incidence, types and risk factors for reoperation within 2 years of primary anterior cruciate ligament reconstruction (ACLR). Methods Our clinic registry was used to identify primary ACLRs, performed from 2005 to 2015, and reoperations performed on the ipsilateral knee within 2 years at our institution. Reoperations were identified using procedural codes and analysis of medical records. A logistic regression analysis was used to evaluate risk factors for reoperation. Results A total of 6030 primary ACLRs were included. A total of 1112 (18.4%) reoperations performed on 1018 (16.9%) primary ACLRs were identified. The most common reoperations were screw removal (n = 282, 4.7%), meniscus procedures (n = 238, 3.9%), cyclops removal/notchplasty (n = 222, 3.7%) and reoperations due to graft rupture (n = 146, 2.4%), including revision ACLR. Age P P P P = 0.005) and lateral meniscus repair (OR 1.38; 95% CI 1.03–1.85; P = 0.02) at primary ACLR were found to be risk factors for reoperation. Conclusion One sixth of all primary ACLRs underwent reoperation due to complications or new injuries within 2 years. The most common reoperations were screw removal, meniscus procedures, cyclops removal/notchplasty and reoperations due to graft rupture, including revision ACLR. Younger age ( Level of evidence III.

Purpose The primary aim of this study was to assess the relationship between the metabolites lactate and pyruvate in the healing tendon after Achilles tendon rupture (ATR) and patient-reported outcome at 6 and 12 months. A secondary aim was to evaluate which underlying factors regulate lactate and pyruvate concentrations. Methods Lactate and pyruvate concentrations were measured two weeks post-operatively in both the healing- and healthy Achilles tendon in 109 patients (90 men, 19 women; mean age 40 ± 7.9 years). Patient demographics, degree of physical activity, timing of surgery, operation time, patient-reported loading and step counts were investigated in relation to metabolite concentrations. At 6 and 12 months, the Achilles tendon Total Rupture Score (ATRS) questionnaire was used to assess patient outcome. Results The mean number of steps taken during the post-operative days 1–10 was the only factor significantly related to the mean concentration of lactate (R2 = 0.34, p = 0.038), and pyruvate (R2 = 0.46, p = 0.006). Pyruvate was demonstrated as the only factor significantly associated with ATRS at both 6 months (R2 = 0.32, p = 0.003) and at 12 months (R2 = 0.37, p = 0.004) using multiple linear regression. Conclusion The mean concentration of pyruvate during early ATR healing may predict patient outcome at 6 and 12 months post-operatively and possibly be used as a biomarker of healing. Early mobilization with an increased number of steps taken is an important clinical strategy to improve the metabolite concentrations during healing. Level of evidence III

Purpose The aim of this study was to investigate whether patient subjective and functional outcomes after Achilles tendon rupture (ATR) are related to deep venous thrombosis (DVT) during leg immobilization. Methods A cohort study with prospectively collected randomized data was conducted between 2010 and 2017. Two-hundred and fifty-one Patients with an Achilles tendon rupture (mean age = 41 ± 8), treated with uniform surgical techniques, were retrospectively analyzed. DVT incidence at 2 and 6 weeks was assessed using compression duplex ultrasound. At 12 months patient-reported outcomes were assessed using the Achilles tendon Total Rupture Score (ATRS), Foot- and Ankle Outcome Score (FAOS), Physical Activity Scale (PAS) and functional outcome with the calf-muscle endurance test. ANOVA analyses were used and adjusted for assumed confounding factors (patient age, sex, BMI and rehabilitation). Results The total DVT incidence was 122 out of 251 (49%). Patients suffering a DVT exhibited significantly lower ATRS at 1 year compared to patients without DVT (mean 76 vs 83, 95% CI 71–79 vs 80–87; p 80) compared to 51% (95% CI 41–61%) of the patients sustaining a DVT (p p p Conclusion Sustaining a DVT during leg immobilization significantly impairs patient-reported outcome at 1 year after surgical repair of ATR. Level of evidence III.

Purpose To compare the preoperative and 1- and 2-year postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores between isolated anterior cruciate ligament reconstruction (ACLR) and ACLR with additional medial meniscus (MM) and/or lateral meniscus (LM) resection or repair. Methods A total of 5,378 patients who underwent primary ACLR, with no associated ligament injuries, at our institution from January 2005 to December 2015 were included. The KOOS subscale scores were used to evaluate patients preoperatively and at 1- and 2-year postoperative follow-up assessments. Patients who underwent isolated ACLR and those who underwent ACLR with additional MM resection, MM repair, LM resection, LM repair, MM plus LM resection, or MM plus LM repair were compared by use of an analysis of covariance, with age, sex, graft, and cartilage injury as covariates. Results Postoperatively, at both 1- and 2-year follow-up assessments, no significant differences were found between the groups for any of the 5 KOOS subscales. Preoperatively, a significant difference between the groups was found for the KOOS Symptoms (P Conclusions Patients undergoing isolated ACLR and those undergoing ACLR with additional MM and/or LM resection or repair obtained equivalent results for each of the KOOS subscales at the 1- and 2-year postoperative follow-up assessments. Differences between the groups were only detectable preoperatively, with patients undergoing ACLR and MM plus LM repair showing the lowest scores for the KOOS Symptoms, Pain, ADL, and Sport/Rec subscales. Level of Evidence Level III, retrospective comparative therapeutic trial.

The effect of surgeon experience on patient outcomes after surgical Achilles tendon rupture (ATR) repair has so far been unknown.To examine whether patient-reported and functional outcomes as well as adverse events after surgical ATR repair differ between orthopaedic specialist surgeons and resident surgeons.Cohort study; Level of evidence, 3.We retrospectively analyzed data from 295 patients treated with surgical ATR repair with standardized techniques. The level of surgeon experience (specialist vs resident) and number of adverse events (rerupture, infection, and deep venous thrombosis) were recorded. Patient-reported and functional outcomes were assessed 12 months postoperatively using the validated Achilles tendon total rupture score (ATRS) and the heel-rise test, respectively. Analysis of covariance was used to compare differences in outcomes between specialist surgeons and resident surgeons. Pearson chi-square or Fisher exact test was used for analysis of adverse events.The mean ATRS at 12 months for patients operated on by resident surgeons was significantly higher compared with specialist surgeons (85.9 [95% CI, 80.3-91.5] vs 77.8 [95% CI, 73.8-81.9];Resident surgeons achieved patient-reported and functional outcomes at least as good as those of specialist surgeons in surgical ATR repair, with a similar risk of adverse events.

Background Acute Achilles tendon rupture (ATR) is a frequently disabling injury, which exhibits unclear variability in long-term functional and patient-reported outcomes. Biomarkers from early healing, which have been shown to be prognostic of long-term outcome would facilitate the development of improved treatment methods. Hypothesis/purpose The aim of this study was to assess essential metabolites pyruvate and its product lactate, as early biomarkers in relation to long-term functional- and patient-reported outcome after ATR. Study design Prospective cohort study. Methods A total of 124 patients (103 men, 21 women; mean age 40 ± 7 years) with ATR, treated with uniform anesthetic and surgical technique, were prospectively assessed. At two weeks post-injury pyruvate and lactate concentrations were assessed in both the injured and uninjured limbs using microdialysis followed by enzymatic quantification. The ratios of the concentration in the injured versus uninjured limb of pyruvate (pyruvate-r) and lactate (lactate-r) were calculated as well as the lactate/pyruvate ratios (L/P-r). At 12 months, patient-reported outcome was examined using self-reported questionnaires; Achilles tendon Total Rupture Score (ATRS), Foot and Ankle Outcome Score (FAOS), and physical activity score. At 12 months, functional outcome was studied using the validated heel-rise test. Results Elevated pyruvate-r, at two weeks, was significantly associated with total ATRS (R = 0.254, P = 0.028), less loss in physical activity (R = 0.241, P = 0.039), less experience of pain in FAOS (R = 0.275, P = 0.032), and a higher number of heel-rise repetitions on injured side (R = 0.230, P = 0.040) at 12 months. Increased lactate-r was related with less strength limitations in the calf (R = 0.283, P = 0.011), while the elevated lactate-pyruvate ratio, notably, was related to more limitations in walking on uneven surface (R = -0,243, P = 0.027). The findings were verified by multiple linear regression taking confounding factors into consideration. Conclusion This study established that the metabolite pyruvate is a good potential biomarker, prognostic of patient outcome at the one-year follow-up after ATR surgery. These novel findings suggest that local biomarkers could be developed at an early-stage screen for new ATR treatments.

Background: Septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) is a rare yet severe complication. The samples in previous studies have been small and without nationwide coverage, making analysis uncertain with a risk of bias. Conclusions to recommend preventive measures are therefore difficult to draw, and it has not been possible to perform a comprehensive risk factor analysis. Purpose: To study the incidence of SA after ACLR in a large, nationwide population and to study the risk factors for SA after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: All ACLRs, primary and revision, in the Swedish Knee Ligament Registry between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of SA events was determined using entries from the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of antibiotics. All events of SA were verified via a review of medical records. Risk factors were analyzed based on data from the registries. Descriptive statistics were used to describe the findings, while logistic regression analysis was used for the risk analysis. Results: The cohort consisted of 26,014 primary and revision ACLRs. During the study period, 298 events of SA (1.1%) were identified. The high-volume units (≥500 ACLRs during the study period) had a distribution of SA between 2 and 47 (0.2%-2.9%). Independent risk factors of SA were male sex (OR, 1.65; 95% CI, 1.28-2.13), operating time ≥70 minutes (OR, 1.83; 95% CI, 1.42-2.36), hamstring tendon autograft (OR, 2.23; 95% CI, 1.21-4.08), and clindamycin as perioperative antibiotic prophylaxis (OR, 1.94; 95% CI, 1.10-3.41). Conclusion: The incidence of SA after ACLR in this nationwide cohort was 1.1%. Male sex, hamstring tendon autografts, and a longer operating time were all independent risk factors for SA. The use of clindamycin as perioperative antibiotic prophylaxis was a risk factor compared with the use of cloxacillin. Some high-volume units had a very low infection rate (0.2%).

Purpose To identify preoperative, intraoperative and postoperative factors associated with revision anterior cruciate ligament reconstruction (ACLR) within 2 years of primary ACLR. Methods Patients who underwent primary ACLR at our institution, from January 2005 to March 2017, were identified. The primary outcome was the occurrence of revision ACLR within 2 years of primary ACLR. Univariate and multivariate logistic regression analyses were used to evaluate preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, graft diameter, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [side-to-side (STS) anterior laxity, limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for revision ACLR. Results A total of 6,510 primary ACLRs were included. The overall incidence of revision ACLR within 2 years was 2.5%. Univariate analysis showed that age 2, time from injury to surgery 5 mm, quadriceps strength and single-leg-hop test LSI of ≥ 90% increased the odds; whereas, MM resection and the presence of a cartilage injury reduced the odds of revision ACLR. Multivariate analysis revealed that revision ACLR was significantly related only to age P P = 0.007) and quadriceps strength LSI of ≥ 90% (OR 1.70; 95% CI 1.16–2.49; P = 0.006). Conclusion Age Level of evidence III.

Background Poisoned patients treated in the Intensive Care Unit are common, representing up to 6% of all ICU admissions. The in-hospital mortality is generally low but little is known about the long-term mortality in these patients. The aim of this study was to describe long-term mortality and cause of death in patients treated in the ICU for poisoning. Method A national observational study based on three registers: the National Patient Register, the Swedish Intensive Care Register and the Cause of Death Register. All patients ≥19 years admitted to a Swedish Intensive Care Unit between January 1, 2010 and December 31, 2011 with an ICD-10 code for poisoning were included. Results A total of 6730 patients were included. The one-year mortality was 4.5% (n = 303), with an overweight of men among the deceased (59.1%, P = 0.002). Patients aged 19-39 years had a 48 times increased one-year mortality compared to the age-matched general population and 94% of these patients died from suicide and/or accident, of which 70% were from a new poisoning. The two-year mortality was 7.2%. Women have a slightly higher overall long-term survival over two years (P Conclusion The risk of premature death is markedly increased in younger patients one and two years after an ICU hospitalisation for non-fatal poisoning compared to the general population. A large majority die due to a new poisoning incident despite a previously known recent severe poisoning. Editorial comment Admission to ICU with poisoning, and particularly self-poisoning, may be associated with long-term mortaliity. In this study of 6730 patients admitted to a Swedish ICU for poisoning, the in-hospital mortality was low for that admission, but there is an increased risk of later mortality in young patients one and two years after hospital discharge.

To identify preoperative and intraoperative factors associated with abnormal anterior knee laxity after primary anterior cruciate ligament (ACL) reconstruction.A total of 5,462 patients who underwent primary ACL reconstruction at our institution from January 2000 to October 2015, with no associated ligament injuries, were included. Demographic data, information regarding graft used, concomitant meniscal surgery, and instrumented laxity were reviewed. The KT-1000 arthrometer, with an anterior tibial load of 134 N, was used to evaluate knee laxity preoperatively and at 6-month follow-up. Patients were considered to have abnormal anterior knee laxity if the postoperative side-to-side difference was greater than 5 mm (International Knee Documentation Committee laxity grade C or D). A logistic regression analysis was used to evaluate whether patient age, gender, preoperative knee laxity, graft type, and presence of medial or lateral meniscus resection or suture were risk factors for abnormal knee laxity.The risk of having abnormal anterior knee laxity was significantly related to younger age (30 years) (odds ratio [OR] 1.44; 95% confidence interval [CI], 1.07-1.95; P = .016), preoperative side-to-side difference greater than 5 mm (OR, 6.57; 95% CI, 4.94-8.73; P.001), hamstring tendon graft (OR, 1.83; 95% CI, 1.08-3.11; P = .025), and medial meniscus resection (OR, 2.22; 95% CI, 1.61-3.07; P.001). Female gender (OR, 0.96; 95% CI, 0.72-1.28; P = .80), medial meniscus suture (OR, 0.82; 95% CI 0.42-1.62; P = .58), lateral meniscus resection (OR, 0.73; 95% CI 0.49-1.10; P = .13), and lateral meniscus suture (OR, 0.99; 95% CI, 0.46-2.11; P = .98) were not associated with increased risk of abnormal knee laxity.Age less than 30 years, preoperative side-to-side difference greater than 5 mm, hamstring tendon graft, and medial meniscus resection are associated with increased risk of having abnormal anterior knee laxity 6 months after primary ACL reconstruction.Level III, retrospective comparative trial.

Purpose To evaluate and compare knee laxity and functional knee outcome between primary and revision anterior cruciate ligament (ACL) reconstruction in the same cohort of patients. Methods Patients who underwent primary and revision ACL reconstruction (ACLR) at Capio Artro Clinic, Stockholm, Sweden, from 2000 to 2015, were identified in our local database. Inclusion criteria were: same patients who underwent primary hamstring tendons (HT) and revision bone–patellar tendon–bone (BPTB) autograft ACLR, no associated ligament injuries and no contralateral ACL injuries/reconstructions. The cause of revision ACLR was graft rupture for all patients. The KT-1000 arthrometer, with an anterior tibial load of 134-N, was used to evaluate knee laxity preoperatively and 6-month postoperatively. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at the 1-year follow-up. Results A total of 118 patients with primary and revision ACLR arthrometric laxity measurements were available (51.0% males; mean age at primary ACLR 21.7 ± 7.1 years and revision ACLR 24.3 ± 7.5 years). The mean preoperative and postoperative anterior side-to-side (STS) difference values were not significantly different between primary and revision ACLR. However, primary ACLR showed a significantly higher frequency of postoperative anterior STS difference > 5 mm compared with revision ACLR (8.4 vs 5.0%; P = 0.02). The KOOS was available for primary and revision ACLR for 73 patients (55.4% males; mean age at primary ACLR 21.6 ± 7 years and revision ACLR 24.7 ± 7.3 years). Preoperatively, revision ACLR showed significantly higher scores in all KOOS subscales, except for the activity of daily living (ADL) subscale. For the primary ACLR, the improvement from preoperatively to the 1-year follow-up was significantly greater in all KOOS subscales and, the postoperative scores were superior for Pain, ADL and Sports subscales compared with revision ACLR. Conclusions The findings of this study showed that anterior knee laxity is restored with revision BPTB autograft ACLR after failed primary HT autograft ACLR, in the same cohort of patients. However, revision ACLR showed a significantly inferior functional knee outcome compared with primary ACLR. It is important for clinicians to inform and set realistic expectations for patients undergoing revision ACLR. Patients must be aware of the fact that having revision ACLR their knee function will not improve as much as with primary ACLR and the final postoperative functional outcome is inferior. Level of evidence Retrospective cohort study, Level III.

Objective We examined whether established metabolic risk genetic variants in the population confer a risk for increased waist circumference in patients with schizophrenia spectrum disorders and also an association with schizophrenia spectrum disorders irrespective of waist circumference. Patients and methods We analyzed the association in (i) a case–case model in which patients with schizophrenia spectrum disorder with increased waist circumference (≥80 cm for women and ≥94 cm for men) (n=534) were compared with patients with normal waist circumference (

Purpose and hypothesis Adjuvant intermittent pneumatic compression (IPC) during leg immobilization following Achilles tendon rupture (ATR) has been shown to reduce the risk of deep venous thrombosis. The purpose of this study was to investigate whether IPC can also promote tendon healing. Methods One hundred and fifty patients with surgical repair of acute ATR were post-operatively leg immobilized and prospectively randomized. Patients were allocated for 2 weeks of either adjuvant IPC treatment (n = 74) or treatment-as-usual (n = 74) in a plaster cast without IPC. The IPC group received 6 h daily bilateral calf IPC applied under an orthosis on the injured side. At 2 weeks post-operatively, tendon healing was assessed using microdialysis followed by enzymatic quantification of tendon callus production, procollagen type I (PINP) and type III (PIIINP) N-terminal propeptide, and total protein content. 14 IPC and 19 cast patients (control group) consented to undergo microdialysis. During weeks 3–6, all subjects were leg-immobilized in an orthosis without IPC. At 3 and 12 months, patient-reported outcome was assessed using reliable questionnaires (ATRS and EQ-5D). At 12 months, functional outcome was measured using the validated heel-rise test. Results At 2 weeks post-rupture, the IPC-treated patients exhibited 69% higher levels of PINP in the ruptured Achilles tendon (AT) compared to the control group (p = 0.001). Interestingly, the IPC-treated contralateral, intact AT also demonstrated 49% higher concentrations of PINP compared to the non-treated intact AT of the plaster cast group (p = 0.002). There were no adverse events observed associated with IPC. At 3 and 12 months, no significant (n.s.) differences between the two treatments were observed using patient-reported and functional outcome measures. Conclusions Adjuvant IPC during limb immobilization in patients with ATR seems to effectively enhance the early healing response by upregulation of collagen type I synthesis, without any adverse effects. Whether prolonged IPC application during the whole immobilization period can also lead to improved long-term clinical healing response should be further investigated. The healing process during leg immobilization in patients with Achilles tendon rupture can be improved through adjuvant IPC therapy, which additionally prevents deep venous thrombosis. Level of evidence Randomized controlled trial, Level I. Electronic supplementary material The online version of this article (doi:10.1007/s00167-017-4621-8) contains supplementary material, which is available to authorized users.

Purpose The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury. Methods Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study. Results Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration. Conclusion The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures. Level of evidence II. Electronic supplementary material The online version of this article (doi:10.1007/s00167-017-4606-7) contains supplementary material, which is available to authorized users.

PurposeThe use of prophylaxis for thromboembolism and infection in anterior cruciate ligament (ACL) reconstruction is not well documented and no general guidelines have been established. The aim of this study was to evaluate the ACL surgeons’ individual strategies of thromboprophylaxis, use of prolonged antibiotic prophylaxis and vancomycin-soaked ACL grafts, and if its use is supported in the current literature. Additionally, the rationale for use of tourniquet was analysed.MethodsQuestionnaires were distributed to all Swedish ACL surgeons who are registered in the Swedish Knee Ligament Register (SKLR), asking about prescription of thromboprophylaxis, prolonged antibiotic prophylaxis, the use of vancomycin-soaked graft and the use of a tourniquet during surgery. The responses were assessed for agreement and the thromboprophylaxis data were analysed in relation to the 2016 SKLR data.Results115 (75%) ACL surgeons responded to the survey. 81.7% prescribed thromboprophylaxis only when risk factors, such as history of thrombosis and the use of oral contraceptives, were present. Female gender, older age and admitted patient were considered the risk factors with the lowest impact. The respondents were generally restrictive regarding the use of prolonged antibiotic prophylaxis. The use of vancomycin-soaked graft was used by only nine (8%) surgeons representing 406 (13%) of the surgeries.ConclusionSwedish ACL surgeons are generally restrictive using thromboprophylaxis and only when risk factors are present. However, there is a lack of consensus in how to weigh the different risk factors and it does not completely adhere to the existing literature.Prolonged antibiotic prophylaxis is rarely used and the use of vancomycin soaking of graft is very limited and applies only to a small number of surgeons. The use of tourniquet is common. There is a need for ACL-specific guidelines regarding the use of thromboprophylaxis.Level of evidenceIV.

Purpose The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. Methods One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. Results At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28–14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. Conclusions Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. Level of evidence Therapeutic, level 1

Objective:. Many trauma patients are at risk of pulmonary embolism due to unrecognized deep vein thrombosis (DVT). Restricted ankle dorsiflexion (AD) range of motion during leg immobilization is known to cause reduced venous blood flow. The aim of the present study was to assess whether AD at plaster cast removal is related to the incidence of DVT and to patient outcome. Design:. Prospective observational cohort study. Setting:. Level 1 Trauma Center. Patients:. A total of 124 patients (97 men, 27 women; mean age 40.3 years) with plaster cast leg immobilization after surgical repair of Achilles tendon rupture were assessed. Main outcome measures:. At 2 weeks postoperatively, assessments of AD and the incidence of DVT using compression duplex ultrasound were performed with observers blinded to patient grouping. Patients were dichotomized into 2 groups; poor or good AD, according to the mean AD, −7°. At 3- and 12 months patient-reported outcome was examined using validated questionnaires (ATRS and FAOS), and functional outcome using the heel-rise test. Results:. Patients with poor AD sustained 42% DVTs, while patients with good AD exhibited a DVT-rate of 23% (P = .036). Logistic regression analysis corroborated this finding (OR = 2.62, P = .036; 95% CI = 1.06–6.44). AD was not linked to any long-term functional or patient-reported outcome. Conclusions:. Reduced AD after plaster cast removal is associated with a higher risk of DVT. The results of this observational study warrant further prospective studies to confirm the effects of ankle dorsiflexion on the risk of developing venous thromboses. Level of evidence: II

Aims Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions. Patients and Methods A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. Results There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). Conclusion Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. Cite this article: Bone Joint J 2016;98-B:1635–41.

Background: Patient outcome after an acute Achilles tendon rupture (ATR) continues to be suboptimal and heterogeneous. Thus, prognostic factors are called for to optimize evidence-based ATR treatment protocols; however, the influence of delayed time from injury to surgery (TTS) on patient outcome after ATR remains largely unknown. Purpose: To determine whether patient outcomes and adverse events after surgical repair of acute ATR are related to delayed TTS. Study Design: Cohort study; Level of evidence, 3. Methods: Two hundred twenty-eight patients with ATR who were treated with uniform anesthetic and surgical techniques, within 10 days after injury, were retrospectively assessed. TTS depended on availability of the operating theater, and neither surgeon nor patient could influence the TTS. Patients were assigned to 1 of 3 groups: short TTS (72 hours). Patient-reported outcome at 1 year was assessed with the validated Achilles tendon Total Rupture Score, with scores higher than 80 on a 0- to 100-point scale indicating an overall good outcome. The incidences of adverse events (perioperative and postoperative) and deep venous thrombosis were assessed. Results: Short TTS was significantly associated with increased rate of good outcome and reduced risk of adverse events. Seventy-one percent (95% CI, 60%-83%) of the patients with short TTS attained a good outcome compared with 44% (95% CI, 33%-56%) of the patients with long TTS ( P = .002), with the intermediate TTS group in between, 63% (95% CI, 47%-78%). The incidence of adverse events was significantly reduced among patients with short TTS, 1.4% (95% CI, 1%-4%) compared with those with intermediate TTS, 11% (95% CI, 2%-21%) ( P = .035) and those with long TTS, 14.8% (95% CI, 7%-23%) ( P = .003). The risk of sustaining a deep venous thrombosis was not statistically significantly different among the 3 groups ( P = .15). Conclusion: Patients with acute ATR undergoing operation within 48 hours after injury had better outcomes and a lower number of adverse events compared with patients undergoing operation after 72 hours. These results align with evidence-based recommendations from other surgical disciplines and should be used as guidelines for optimizing ATR treatment protocols. Registration: NTC01317160 (ClinicalTrials.gov identifier).

To analyse the non-response group in the Swedish Knee Ligament Register (SKLR). All 3588 patients in the SKLR who had undergone anterior cruciate ligament surgery in 2010 were included. Respondents (n = 1865) and non-respondents (n = 1723) at the 2-year follow-up survey were assessed for potential differences in demographics and baseline data. KOOS/EQ5D questionnaires were sent to non-respondents together with a non-response survey asking questions about reasons for dropout. Respondents had a significantly higher mean age (27.8 years, range 9–64) than non-respondents (25.9 years, range 12–65) (p

Having three or more persisting (i.e.3 months) post-concussion symptoms (PCS) affects a significant number of patients after a mild traumatic brain injury (mTBI). A common complaint is cognitive deficits. However, several meta-analyses have found no evidence of long-term cognitive impairment in mTBI patients. The study sought to answer two questions: first, is there a difference in cognitive performance between PCS and recovered mTBI patients? Second, is lower cognitive reserve a risk factor for developing PCS?Prospective inception cohort study.One hundred and twenty-two adult patients were recruited from emergency departments within 24 hours of an mTBI. Three months post-injury, participants completed the Rivermead Post Concussion Symptoms Questionnaire and a neuropsychological assessment. A healthy control group (n = 35) were recruited. The estimate of cognitive reserve was based upon sub-test Information from Wechsler Adult Intelligence Scale and international classifications of educational level and occupational skill level.mTBI patients showed reduced memory performance. Patients with lower cognitive reserve were 4.14-times more likely to suffer from PCS.mTBI may be linked to subtle executive memory deficits. Lower cognitive reserve appears to be a risk factor for PCS and indicates individual vulnerabilities.

BACKGROUND Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients. METHOD A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register). RESULTS The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P

Patients with acute Achilles tendon rupture (ATR) display an extended healing process with varying clinical outcome. Poor microcirculatory blood flow has been suggested to be a significant factor for the healing process. However, whether microcirculation may predict healing outcome has been mostly unknown. Therefore, we investigated whether blood flow in the Achilles tendon may be associated with patient-reported and functional outcomes after ATR. In vivo laser-Doppler flowmetry was used to assess microvascular blood flow bilateral in the Achilles tendons, during post-occlusive reactive hyperemia, of nine patients with acute total ATR at 2 weeks post-operatively. At 3 months post-operatively, patient-reported outcome was assessed using Achilles tendon Total Rupture Score (ATRS). At 1 year a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining validated, independent, patient-reported (ATRS), and functional outcome (heel-rise test) measures. An improved combined patient-reported and functional outcome, ACOS, at 1 year was significantly correlated with higher maximum blood flow (r=.777, P=.040) in the injured limb. Furthermore, enhanced patient-reported outcome, ATRS, at 3 months, was associated with an elevated ratio of maximum to resting blood flow (r=.809, P=.015) in the uninjured limb. Blood flow in early tendon healing is associated with long-term patient-reported and functional outcomes after ATR. The microcirculatory blood flow of both the healing and contralateral Achilles tendon seems to determine the healing potential after injury.

Cognitive deficits represent a significant characteristic of schizophrenia. However, a majority of the clinical studies have been conducted in antipsychotic drug treated patients. Thus, it remains unclear if significant cognitive impairments exist in the absence of medication. This is the first meta-analysis of cognitive findings in drug-naïve patients with schizophrenia. Cognitive data from 23 studies encompassing 1106 patients and 1385 controls published from 1992 to 2013 were included. Tests were to a large extent ordered in cognitive domains according to the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery. Analysis was performed with STATA using the random-effects model and heterogeneity as well as Egger's publication bias was assessed. Overall the results show that patients performed worse than healthy controls in all cognitive domains with medium to large effect sizes. Verbal memory, speed of processing and working memory were three of the domains with the greatest impairments. The pattern of results is in line with previous meta-analytic findings in antipsychotic treated patients. The present meta-analysis confirms the existence of significant cognitive impairments at the early stage of the illness in the absence of antipsychotic medication.

Improved Health-related quality of life (HRQoL) is an alternative treatment goal for individuals with psychosis, who have up to two times greater prevalence of type 2 diabetes, hypertension and obesity than the general population. Aim: to compare HRQoL in patients with psychosis, especially schizophrenia, with a reference sample and explore the relationship between HRQoL and metabolic risk factors in these patients. Methods: a prospective cohort study was carried out in specialized psychiatric outpatient departments in Sweden. The patients were invited consecutively. A prospective population-based study of public health in the south-east of Sweden served as reference group. Patients were assessed with psychiatric questionnaires that included Global Assessment of Functioning (GAF). Health-related quality of life was assessed using the questionnaire EQ5D, both for patients and the population, and several other health status outcomes were used. Results: At 73%, schizophrenia and schizoaffective disorder were the most common diagnoses in the patient group. The results in patients (n = 903) and population (n = 7238) showed significant differences in lower EQ5D among patients. According to the definition by the International Diabetes Federation (IDF), elevated blood pressure was the only metabolic risk associated with lower HRQoL in patients. Raised LDL-cholesterol levels were also significantly related to lower HRQoL. Conclusion: patients suffering from psychosis had significantly lower HRQoL regarding all components in EQ5D, except for the pain/discomfort component. Almost half of the patient group met the criteria for metabolic syndrome. According to the IDF criteria, elevated blood pressure was the only metabolic risk factor that had an impact on HRQoL.

Objective to compare early discharge with home care versus standard postpartum care in terms of mothers' sense of security; contact between mother, newborn and partner; emotions towards breast feeding; and breast-feeding duration at one and three months after birth. Design retrospective case-control study. Setting a labour ward unit in Stockholm, Sweden handling both normal and complicated births. Participants 96 women with single, uncomplicated pregnancies and births, and their healthy newborns. Intervention early discharge at 12–24 hours post partum with 2–3 home visits during the first week after birth. The intervention group consisted of women who had a normal vaginal birth ( n =45). This group was compared with healthy controls who received standard postnatal care at the hospital ( n =51). Instruments mothers' sense of security was measured using the Parents' Postnatal Sense of Security Scale. Contact between mother, child and father, and emotions towards breast feeding were measured using the Alliance Scale, and breast-feeding rates at one and three months post partum were recorded. Findings women in the intervention group reported a greater sense of security in the first postnatal week but had more negative emotions towards breast feeding compared with the control group. At three months post partum, 74% of the newborns in the intervention group were fully breast fed versus 93% in the control group ( p =0.021). Contact between the mother, newborn and partner did not differ between the groups. Conclusion early discharge with home care is a feasible option for healthy women and newborns, but randomised controlled studies are needed to investigate the effects of home care on breast-feeding rates.

Psychosis is associated with excess cardiovascular morbidity and mortality.To determine the prevalence of cardiovascular risk factors in patients with psychotic disorders compared with the population.731 consecutive patients with psychosis recruited from psychiatric outpatient clinics in Stockholm County, Sweden, were compared with 5580 individuals from a population study performed in the same area. The main outcome measures were waist circumference, body mass index (BMI) and fasting glucose.Mean waist circumference in patients vs. controls was for males 106 and 94 cm, respectively, and for females 97 and 85 cm, respectively (P0.001); mean fasting glucose in patients vs. controls was for males 5.8 and 5.2 mmol/l, respectively, and for females 5.6 and 4.8 mmol/l, respectively (P0.001). Comparisons were controlled for differences in age and family history of diabetes. Increased waist circumference was more common in psychotic patients compared with controls (OR = 3.99; 95% CI 3.09-5.15), controlling for fasting insulin, differences in gender, blood pressure, fasting glucose, family history of diabetes, age and tobacco use. Increased fasting blood glucose was also more common in psychotic patients (OR = 2.41; 95% CI 1.84-3.14) controlling for the same factors with the exception of fasting glucose and with the addition of increased waist circumference.Our study shows that the psychosis illness per se can be considered as a cardiovascular risk factor, independent of the traditional risk factors such as age and smoking.

Purpose Functional weight-bearing mobilization may improve repair of Achilles tendon rupture (ATR), but the underlying mechanisms and outcome were unknown. We hypothesized that functional weight-bearing mobilization by means of increased metabolism could improve both early and long-term healing. Methods In this prospective randomized controlled trial, patients with acute ATR were randomized to either direct post-operative functional weight-bearing mobilization (n = 27) in an orthosis or to non-weight-bearing (n = 29) plaster cast immobilization. During the first two post-operative weeks, 15°–30° of plantar flexion was allowed and encouraged in the functional weight-bearing mobilization group. At 2 weeks, patients in the non-weight-bearing cast immobilization group received a stiff orthosis, while the functional weight-bearing mobilization group continued with increased range of motion. At 6 weeks, all patients discontinued immobilization. At 2 weeks, healing metabolites and markers of procollagen type I (PINP) and III (PIIINP) were examined using microdialysis. At 6 and 12 months, functional outcome using heel-rise test was assessed. Results Healing tendons of both groups exhibited increased levels of metabolites glutamate, lactate, pyruvate, and of PIIINP (all p

Since Achilles tendon healing is protracted, more knowledge of metabolites known to meet the demands for biosynthesis and proliferation is needed. We hypothesized that essential metabolites, glutamate, glucose, lactate, pyruvate and glycerol, are present and upregulated in healing Achilles tendons. We moreover hypothesized that adjuvant intermittent pneumatic compression (IPC), which increases blood flow, upregulates metabolite concentrations. Twenty patients with acute Achilles tendon rupture were recruited, operated, and included. The control group, 15 patients, received plaster cast immobilization, while five patients received adjuvant foot IPC beneath the plaster cast. At 2 weeks postoperatively, microdialysis of the healing and contralateral intact Achilles tendons was followed by quantification of metabolites. Healing compared to intact tendons of the controls exhibited significantly increased concentrations (mM) of glutamate (60 ± 14 vs 20 ± 11), lactate (1.15 ± 0.60 vs 0.64 ± 0.35), and pyruvate (81 ± 29 vs 35 ± 25, μM). Healing tendons of the IPC vs control group displayed higher levels of glutamate (84 ± 15 vs 62 ± 16) and glucose (3.44 ± 0.62 vs 2.62 ± 0.72); (P

Objective: Several genetic loci have been suggested to be associated with bipolar disorder but results have been inconsistent. Studying associations between bipolar symptoms and candidate genes may better expose this relationship. Here we investigate the association between bipolar key symptoms and the P2RX7 gene. Methods: Key symptoms of mania were rated in two sets of medicated bipolar disorder patients (n = 171 and n = 475) at two specialized outpatient clinics for affective disorders and three regular psychiatric outpatient units in Sweden. The relationships between all manic symptoms according to DSM-IV were entered in a principal component analysis. We used a case-case model to reduce the genetic heterogeneity and tested associations between four factors related to manic symptoms and their association to four single nucleotide polymorphisms in the P2RX7 gene. Results: The combination of the cognitive symptoms, distractibility, talkativeness, and thought disorder was significantly associated with rs1718119 in the P2RX7 gene in Set 1 [odds ratio (OR) = 1.78; p = 0.011]. The association was re-tested in the second set (OR = 1.42; p = 0.009). In the total sample, the association was even stronger (OR = 1.49; p < 0.001). None of the other factors was associated with the P2RX7 gene. Within the first factor, the distractibility symptom accounted for a significant portion of the association to rs1718119 (p = 0.016). Conclusion: There is an association between specific symptoms of bipolar disorder and the P2RX7 gene. This finding may open up new approaches to elucidating the neurobiology behind bipolar symptoms.

Objective To evaluate the impact of personality, socio-demographic and obstetric factors on birth experience in a cohort of healthy first-time mothers. A second aim was to compare a visual analogue scale and Wijma Delivery Experience Questionnaire B as instruments evaluating birth experience. Material and methods In total, 541 women were prospectively followed from the end of pregnancy until 9 months postpartum. Socio-demographic, psychological and somatic data as well as personality characteristics were collected. Experience of delivery was measured with a visual analogue scale and with Wijma Delivery Experience Questionnaire B. Sixty-three variables were considered to be associated with the experience of delivery. Nineteen of these, found to be significantly associated with birth experience, were entered in a logistic regression analysis. Results The logistic regression analysis showed that a memory of pain during birth, high usage of analgesics postpartum, long hospital stay, worry in late pregnancy and high self-rated irritation were related to a more negative birth experience, while high confidence in the midwife was related to a more positive experience. The correlation between experiences of delivery rated by Wijma Delivery Experience Questionnaire B and the visual analogue scale was 0.52 (p Conclusion To help women to cope with pain during and after birth could be an important factor to improve birth experience. Even though the correlation between the visual analogue scale and Wijma Delivery Experience Questionnaire B was moderate, the visual analogue scale could be used as a simple method for screening of birth experience.

In previous studies of the present patients with schizophrenia, aberrant tyrosine transport across the fibroblast membrane was found. A low K(m), a kinetic factor indicating high affinity between tyrosine and the binding site at the cell membrane, was found to be associated with poor cognitive functions in patients. The present study aimed at investigating possible relationships between patients with schizophrenia and their first-degree relatives in aberrant tyrosine transport indicating that it may be a biological marker for the genetic susceptibility.Thirty-three parents, 13 fathers and 20 mothers, from 23 families with a schizophrenic patient agreed to enter the study. They underwent skin biopsies for fibroblast cultivation, neuropsychological and psychiatric investigations and were classified as family history positive or negative. Tyrosine transport kinetics (K(m) and V(max)) were calculated from in vitro trials of gradients of extracellular tyrosine concentrations in fibroblast cultures.An association between patients with schizophrenia and their mothers were found for a low K(m) indicating maternal inheritance. Mothers displaying a low K(m) performed worse on the neuropsychological tests compared to mothers with normal K(m). Corresponding relationships between a low K(m) and neurocognitive dysfunction had previously been found for the patients.An aberrant tyrosine transport across plasma membrane may constitute a biological marker for an endophenotype within the schizophrenia spectrum with low cognitive functioning. A plausible mode for genetic transmission is maternal inheritance.

The abuse of flunitrazepam (FZ) compounds is worldwide, and several studies have reflected on the consequences with regard to violence, aggression and criminal lifestyle of FZ users. Criminals take high doses of FZ or some other benzodiazepines to "calm down" before the planned crime. There is support from earlier studies that most likely, all benzodiazepines may increase aggression in vulnerable males. Chronic intake of high doses of FZ increases aggression in male rats. Because psychopathy involves aggression, we have examined whether psychopathy as well as any of the four facets of the Psychopathy Checklist-Revised (PCL-R) (Interpersonal, Affective, Lifestyle and Antisocial) are related to different substance use disorders, with the focus on FZ. We have also examined the relationship between each PCL-R item and FZ use. Participants were 114 male offenders aged 14-35 years, all of whom were convicted for severe, predominantly violent, offences. Substance use, including FZ, was not more common in those who scored high in psychopathy. Use of FZ was more common in offenders who scored high in Facet 4 (Antisocial) of the PCL-R (odds ratio = 4.30, 95% CI 1.86-9.94). Only one of the PCL-R items, "Criminal versatility", was significantly associated with FZ use (odds ratio = 3.7). It may be concluded that intake of FZ has a specific relationship to only one of the facets and not to psychopathy per se. The findings have also important theoretical implications because Facet 4 is not a key factor of the construct of psychopathy. Clinical implications of the article: We have used the new two-factor and four-facet theoretical model of psychopathy in the young offender population, many of them with one or more substance use disorders. The present results suggest that antisocial behavior defined by Facet 4 (poor behavioral control, early behavior problems, juvenile delinquency, revocation of conditional release and criminal versatility) in the studied subjects is more typical for FZ users than it is for non-FZ users. This may have implications for assessment and treatment. Clinicians should be aware that criminals with high scores on Facet 4 have a more than fourfold odds of being a FZ user. This conclusion has an important clinical implication because FZ abuse is very common and is not always the focus of a forensic psychiatric assessment.

The effectiveness of a brief intervention based on individual cognitive behavioral counseling in mothers with signs of postnatal depression was evaluated. Patients undergoing a complicated delivery were invited to participate. Women who scored above a cut-off level (>12) on Edinburgh Postnatal Depression Scale (EPDS) were randomized to either a brief individual cognitive behavioral counseling comprising three weekly 1 hour sessions (n = 33) or standard care (n = 34). Measures of postnatal depression were collected from EPDS, 1 month after birth and 1 month after treatment. Both groups showed a significant decline from baseline to follow-up, mean scores declined from 16.9 to 7.6 (intervention group) vs. 13.6 to 9.9 (control group; p < 0.001). There was a significant interaction effect (Group*Time) between the intervention and the control group showing a more rapid decline of EPDS scores for the intervention group (p < 0.001). The results suggest that brief cognitive behavioral counseling is an effective treatment in women at risk for developing postnatal depression.

ObjectiveProlonged post-concussive symptoms (PCS) affect a significant minority of patients withmild traumatic brain injury (mTBI). The aetiology is multifactorial depending on preinjury as well as peri-injury and postinjury factors. In this study, we examine outcome from an emotional reserve perspective.DesignProspective cohort study.SettingPatients were recruited from three emergency departments in major university hospitals in Stockholm, Sweden. Follow-up data were collected in an outpatient setting at one of the recruiting hospitals.Participants122 patients with a history of blunt head trauma (aged 15–65 years; admitted for mTBI within 24 hours after trauma (Glasgow Coma Scale score of 14–15, loss of consciousness ProcedureRecruitment in three emergency departments. Initial assessments were made within 1 week after the injury. Patients were mailed the follow-up questionnaires 1 year postinjury.Outcome measuresA psychiatric assessment was performed at 1 week post injury. The participants also completed a personality inventory, measures of psychological resilience, depression, anxiety and post-traumatic symptoms. One-year outcome was measured by the Rivermead Post Concussion Symptoms and the Rivermead Head Injury Follow-Up questionnaires.ResultsThe psychiatric assessment revealed more symptoms of anxiety, depression and post-traumatic symptoms in the acute stage for patients who later developed PCS.After 1 year, 94 participants were still in the programme (male/female 57/37) and 12% matched the extended criteria for PCS (≥3 symptoms and ≥2 disabilities). PCS patients reported more preinjury and concurrent psychiatric problems, lower level of functioning before the injury and experienced more stress. They showed higher somatic trait anxiety, embitterment, mistrust and lower level of psychological resilience than recovered participants.ConclusionIntrapersonal emotional reserve shape the emergence and persistence of PCS after mTBI.

Objective To investigate contact between mothers and their newborn child and study if there are differences between those who requested an elective caesarean section compared to women who had a vaginal birth and those who underwent an elective caesarean section due to obstetrical indication. The psychometric properties of a scale that measure the contact between mother and child were also investigated. Design A prospective cohort study. Setting Danderyd Hospital, Stockholm, Sweden. Sample 510 primiparas from three groups: women undergoing caesarean section on maternal request ( n =96), women undergoing caesarean section on obstetrical indication ( n =116) and women planning a vaginal delivery ( n =198). The later were further divided into subgroups; women who underwent assisted vaginal delivery ( n =35) and women who had an emergency caesarean section ( n =65). Methods The instrument used was the Alliance Scale. Main outcome measure The contact between mother and child in relation to mode of delivery. Results The contact with the child was rated as positive on all occasions: there were no significant differences between the groups. The relation to the partner was rated as positive at all occasions. Mothers with a vaginal delivery experienced breastfeeding less stressful than the mothers with a caesarean delivery. Three and nine months after delivery the mothers with a caesarean delivery on request reported more breastfeeding problems than mothers in the other groups. Mothers with a vaginal delivery rated less sadness at every occasion. Conclusion Mode of delivery does not seem to affect how mothers experience their contact towards the newborn child.