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Maria Belland Olsen,1,2 Camilla Huse,1,2 Mirta Mittelstedt Leal de Sousa,3,4 Sarah Louise Murphy,1,2 Antonio Sarno,3,5 Tobias Sebastian Obermann,3 Kuan Yang,1 Jan Cato Holter,2,6 Marte Jøntvedt Jørgensen,2,7 Erik Egeland Christensen,2,7 Wei Wang,3 Ping Ji,3 Lars Heggelund,8,9 Hedda Hoel,1,10 Anne Margarita Dyrhol-Riise,2,7 Ida Gregersen,1 Pål Aukrust,1,2,11 Magnar Bjørås,3,6 Bente Halvorsen,1,2 Tuva Børresdatter Dahl12 1Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway; 2Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 3Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 4Proteomics and Modomics Experimental Core Facility (PROMEC), NTNU, Trondheim, Norway; 5Department of Fisheries and New Biomarine Industry, SINTEF Ocean, Trondheim, Norway; 6Department of Microbiology, Oslo University Hospital and University of Oslo, Oslo, Norway; 7Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway; 8Department of Internal Medicine, Vestre Viken Hospital Trust, Drammen, Norway; 9Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway; 10Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; 11Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway; 12Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, NorwayCorrespondence: Tuva Børresdatter Dahl, Division of Critical Care and Emergencies and Research Institute of Internal Medicine, Oslo University Hospital, Sognsvannsveien 20, Oslo, Norway, Tel +4723072786, Email t.b.dahl@medisin.uio.noPurpose: Reactive oxygen species (ROS) are an important part of the inflammatory response during infection but can also promote DNA damage. Due to the sustained inflammation in severe Covid-19, we hypothesized that hospitalized Covid-19 patients would be characterized by increased levels of oxidative DNA damage and dysregulation of the DNA repair machinery.Patients and Methods: Levels of the oxidative DNA lesion 8-oxoG and levels of base excision repair (BER) proteins were measured in peripheral blood mononuclear cells (PBMC) from patients (8-oxoG, n = 22; BER, n = 17) and healthy controls (n = 10) (Cohort 1). Gene expression related to DNA repair was investigated in two independent cohorts of hospitalized Covid-19 patients (Cohort 1; 15 patents and 5 controls, Cohort 2; 15 patients and 6 controls), and by publicly available datasets.Results: Patients and healthy controls showed comparable amounts of oxidative DNA damage as assessed by 8-oxoG while levels of several BER proteins were increased in Covid-19 patients, indicating enhanced DNA repair in acute Covid-19 disease. Furthermore, gene expression analysis demonstrated regulation of genes involved in BER and double strand break repair (DSBR) in PBMC of Covid-19 patients and expression level of several DSBR genes correlated with the degree of respiratory failure. Finally, by re-analyzing publicly available data, we found that the pathway Hallmark DNA repair was significantly more regulated in circulating immune cells during Covid-19 compared to influenza virus infection, bacterial pneumonia or acute respiratory infection due to seasonal coronavirus.Conclusion: Although beneficial by protecting against DNA damage, long-term activation of the DNA repair machinery could also contribute to persistent inflammation, potentially through mechanisms such as the induction of cellular senescence. However, further studies that also include measurements of additional markers of DNA damage are required to determine the role and precise molecular mechanisms for DNA repair in SARS-CoV-2 infection.Keywords: Covid-19, oxidative stress, DNA damage, DNA repair, base excision repair, double strand break repair

Ninna Hinchely Ebdrup,1– 3 Anders Hammerich Riis,4,5 Cecilia Høst Ramlau-Hansen,2 Bjørn Bay,1,6 Julie Lyngsø,7 Dorte Rytter,2 Marianne Johansson Jørgensen,4 Ulla Breth Knudsen1,3 1Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Horsens, Denmark; 2Department of Public Health, Aarhus University, Aarhus, Denmark; 3Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; 4Department of Research, Regional Hospital Horsens, Horsens, Denmark; 5Enversion A/S, Aarhus, Denmark; 6Maigaard Fertility Clinic, Aarhus, Denmark; 7Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, DenmarkCorrespondence: Ninna Hinchely Ebdrup, Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Sundvej 30, Horsens, 8700, Denmark, Tel +45 28 47 21 11, Email ninebd@clin.au.dkPurpose: Infertility may affect somatic and mental health later in life. Nevertheless, health status before diagnosed infertility is sparsely studied in women. We aimed to describe healthcare use in primary and secondary care before a first infertility diagnosis and compare use between cases and controls.Materials and Methods: The case–control study was based on register data and used incidence density sampling. From the CROSS-TRACKS Cohort, we included women residing in the Horsens area in Denmark in 2012– 2018 (n = 54,175). Eligible women were aged 18– 40 years, nulliparous, and living in heterosexual relationships. Cases were women with a first infertility diagnosis in the Danish National Patient Registry (index date). Five controls were matched on age, birth year, and calendar time. Through linkage to Danish national health registries, we identified general practitioner (GP) attendance, paraclinical examinations, hospital contacts, diagnoses, and redeemed prescriptions. Healthcare use from one year to five years before index date was compared with conditional logistic regression.Results: We identified 711 cases and 3555 controls. At one year before index date, cases consulted their GP (odds ratio (OR) = 5.2, 95% confidence interval (CI): 3.2, 8.3) and visited hospital (OR = 1.2, 95% CI: 1.0, 1.4) and redeemed prescriptions (OR = 2.3 95% CI: 1.9, 2.7) more often compared to controls. Cases more often had blood and hemoglobin tests performed, redeemed more drugs related to genitourinary and hormonal diseases, and were more often diagnosed with endocrine and genitourinary diseases in the year before a first infertility diagnosis compared to controls. Cases and controls had comparable healthcare use from five years to one year before a first infertility diagnosis.Conclusion: Cases and controls had similar healthcare use from five years to one year before a first infertility diagnosis. However, cases had a higher healthcare use in the year preceding a first infertility diagnosis compared to controls.Keywords: behavior, health status, incidence density, fertility, preconception health, medically assisted reproduction

It has been proposed that poor semen quality may have its origins from fetal programming due to environmental factors. We investigated whether maternal coffee consumption during early pregnancy was associated with biomarkers of reproductive health in adult sons in the Fetal Programming of Semen Quality (FEPOS) cohort. In 2017-2019, 1058 young men provided a semen and blood sample and self-measured their testis volume. Daily maternal coffee consumption was reported by the mothers around gestational week 17. We estimated relative percentage differences with 95 % confidence intervals (CI) for semen quality measures, testis volume, and reproductive hormone levels according to maternal coffee consumption during pregnancy. Maternal coffee consumption (yes/no (reference)) was associated with lower semen volume (-7.0 % (95 % CI:-12.9;-0.7)), lower proportion of morphologically normal spermatozoa (-8.3 % (95 % CI:-16.5;0.8)), higher proportion of non-progressive and immotile spermatozoa (4.3 % (95 % CI:-1.5;10.3)), and lower testis volume (-4.8 % (95 % CI:-9.0;-0.4)). No indication of a dose-response association or threshold effects was observed in the categorized and continuous analyses. No associations with reproductive hormone levels were observed in any of the analyses. Overall, the study does not provide obvious indications that maternal coffee consumption in early pregnancy deteriorates male offspring fecundity. While some minor changes were observed, most estimates were small with confidence intervals overlapping the null. Future studies, preferably with greater exposure contrast, are warranted before a conclusion can be drawn as to whether maternal coffee consumption during pregnancy constitutes a risk for reproductive health in adult sons., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Cecilia Ramlau-Hansen reports financial support was provided by European Research Council. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

A recent advancement in consciousness science has been the introduction of a multidimensional framework of consciousness. This framework has been applied to global states of consciousness, including psychedelic states and disorders of consciousness, and the consciousness of non-human animals. The multidimensional framework enables a finer parsing of both various states of consciousness and forms of animal consciousness, paving the way for new scientific investigations into consciousness. In this paper, the multidimensional model is expanded by constructing temporal profiles. This expansion allows for the modelling of changes in consciousness across the life cycles of organisms and the progression over time of disorders of consciousness. The result of this expansion is 2-fold: (i) it enables new modes of comparison, both across stages of development and across species; (ii) it proposes that more attention be given to the various types of fluctuations that occur in patients who are suffering from disorders of consciousness., Competing Interests: None declared., (© The Author(s) 2024. Published by Oxford University Press.)

People living with multiple chronic illnesses and an increasing need for acute care is a global health challenge, which questions the conventional ways of managing illness. A central issue is how medical practices can become more patient-centred and aligned with the everyday life of patients. Communicative strategies for eliciting the patient's goals and preferences are often proposed. In this article, we draw on ethnographic data from fieldwork conducted during 2019-2020 in health-care settings and among people living with multiple chronic illness(es) and repeated acute admissions in Denmark. Inspired by science and technology studies of chronic illness and care, we trace the enactments of illness and illness work in a patient trajectory marked by persistent symptoms and medical complexity. We analyse three medical encounters, and we show how 'tinkering' with clinical signs and utterances in each encounter constantly enacts new versions, shaping how the patient could and should live with his illness. We argue that specialised outpatient check-ups for these patients must provide space for continuous tinkering with the concrete effects of illness in everyday life., (© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

Background: Current tuberculosis treatment regimens could be improved by adjunct host-directed therapies (HDT) targeting host responses. We investigated the antimycobacterial capacity of macrophages from patients with tuberculosis in a phase 1/2 randomized clinical trial (TBCOX2) of the cyclooxygenase-2 inhibitor etoricoxib., Methods: Peripheral blood mononuclear cells from 15 patients with tuberculosis treated with adjunctive COX-2i and 18 controls (standard therapy) were collected on day 56 after treatment initiation. The ex vivo capacity of macrophages to control mycobacterial infection was assessed by challenge with Mycobacterium avium, using an in vitro culture model. Macrophage inflammatory responses were analyzed by gene expression signatures, and concentrations of cytokines were analyzed in supernatants by multiplex., Results: Macrophages from patients receiving adjunctive COX-2i treatment had higher M. avium loads than controls after 6 days, suggesting an impaired capacity to control mycobacterial infection compared to macrophages from the control group. Macrophages from the COX-2i group had lower gene expression of TNF, IL-1B, CCL4, CXCL9, and CXCL10 and lowered production of cytokines IFN-β and S100A8/A9 than controls., Conclusions: Our data suggest potential unfavorable effects with impaired macrophage capacity to control mycobacterial growth in patients with tuberculosis receiving COX-2i treatment. Larger clinical trials are required to analyze the safety of COX-2i as HDT in patients with tuberculosis., Clinical Trials Registration: NCT02503839., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: Based on the principle of the autonomy of the patient, shared decision-making (SDM) is the ideal approach in clinical encounters. In SDM, patients and healthcare professionals (HCPs) share knowledge and power when faced with the task of making decisions. However, patients are often not involved in the decision-making process. In this study, we explore medication decision-making during hospitalization and how power in the specific patient-HCP relationship is articulated, as analysed by Foucauldian theory., Methods: A qualitative case study, comprising observations of patient-HCP encounters at an internal medicines ward at a university hospital in Norway, followed by semi-structured interviews. The narratives ( n  = 4 patients) were selected from a larger study ( n  = 15 patients). The rationale behind the choice of these patients was to include diverse and rich accounts. The four patients in their 40s-70s were included close to the day of presumed discharge., Results: The narratives provide an insight into the patients as persons, their perspectives, including what mattered to them during their hospitalization, especially in relation to medications. Overall, SDM was not observed in this study. Even though all the participants actively tried to keep their autonomous capacity and to resist the HCPs' use of power, they were not able to change the established dynamics. Moreover, they were not allowed an equal voice to those of HCPs and thus not to escape the system's objectification and subjectification of them., Conclusion: There is a need for HCPs to get more familiarized with SDM. The healthcare system and the individual HCP need to make more room for dialogue with the patients about their preferences. A part of this is also how health care systems are structured and scheduled, thus, it is important to empower patients and HCPs alike.

Throughout the COVID-19 pandemic, several variants of concern (VoC) of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have evolved, affecting the efficacy of the approved COVID-19 vaccines. To address the need for vaccines that induce strong and persistent cross-reactive neutralizing antibodies and T cell responses, we developed a prophylactic SARS-CoV-2 vaccine candidate based on our easily and rapidly adaptable plasmid DNA vaccine platform. The vaccine candidate, referred to here as VB2129, encodes a protein homodimer consisting of the receptor binding domain (RBD) from lineage B.1.351 (Beta) of SARS-CoV-2, a VoC with a severe immune profile, linked to a targeting unit (human LD78β/CCL3L1) that binds chemokine receptors on antigen-presenting cells (APCs) and a dimerization unit (derived from the hinge and C H 3 exons of human IgG3). Immunogenicity studies in mice demonstrated that the APC-targeted vaccine induced strong antibody responses to both homologous Beta RBD and heterologous RBDs derived from Wuhan, Alpha, Gamma, Delta, and Omicron BA.1 variants, as well as cross-neutralizing antibodies against these VoC. Overall, preclinical data justify the exploration of VB2129 as a potential booster vaccine that induces broader antibody- and T cell-based protection against current and future SARS-CoV-2 VoC., (© 2023. The Author(s).)

Background: The increasing aging population and limited health care resources have placed new demands on the healthcare sector. Reducing the number of hospitalizations has become a political priority in many countries, and special focus has been directed at potentially preventable hospitalizations., Objectives: We aimed to develop an artificial intelligence (AI) prediction model for potentially preventable hospitalizations in the coming year, and to apply explainable AI to identify predictors of hospitalization and their interaction., Methods: We used the Danish CROSS-TRACKS cohort and included citizens in 2016-2017. We predicted potentially preventable hospitalizations within the following year using the citizens' sociodemographic characteristics, clinical characteristics, and health care utilization as predictors. Extreme gradient boosting was used to predict potentially preventable hospitalizations with Shapley additive explanations values serving to explain the impact of each predictor. We reported the area under the receiver operating characteristic curve, the area under the precision-recall curve, and 95% confidence intervals (CI) based on five-fold cross-validation., Results: The best performing prediction model showed an area under the receiver operating characteristic curve of 0.789 (CI: 0.782-0.795) and an area under the precision-recall curve of 0.232 (CI: 0.219-0.246). The predictors with the highest impact on the prediction model were age, prescription drugs for obstructive airway diseases, antibiotics, and use of municipality services. We found an interaction between age and use of municipality services, suggesting that citizens aged 75+ years receiving municipality services had a lower risk of potentially preventable hospitalization., Conclusion: AI is suitable for predicting potentially preventable hospitalizations. The municipality-based health services seem to have a preventive effect on potentially preventable hospitalizations., Competing Interests: The authors declares no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Study Question: Is maternal age at menarche associated with reproductive health in sons measured by semen quality, testes volume and reproductive hormone levels?, Summary Answer: Later maternal age at menarche was associated with impaired semen characteristics, lower testes volume and altered levels of reproductive hormones, while earlier maternal age at menarche was not strongly associated with reproductive outcomes in sons., What Is Known Already: Both earlier and later maternal age at menarche may be associated with altered male reproductive health outcomes. This is the first study to investigate the potential association between maternal age at menarche and semen quality, testes volume and reproductive hormone levels in sons., Study Design, Size, Duration: In this population-based cohort study, we used data from the Fetal Programming of Semen Quality Cohort nested within the Danish National Birth Cohort. In total, 5697 sons born in 1998-2000 were invited to participate in the cohort in 2017-2019., Participants/materials, Setting, Methods: In total, 1043 (18% of the invited) young men with information on maternal age at menarche provided a semen and blood sample, measured their testes volume, and filled in a questionnaire on health behavior and pubertal development. Maternal age at menarche was reported by the mothers during pregnancy and examined categorically (as earlier, at the same time or later than their peers), continuously and modeled as splines. We estimated relative percentage differences in the reproductive outcomes using negative binomial regression models. Further, we did a mediation analysis to investigate the potential mediating role of timing of the sons' pubertal development., Main Results and the Role of Chance: Sons whose mothers had age at menarche later than peers had 15% lower (95% CI: -27%; 0%) sperm concentration, 14% lower (95% CI: -28%; 1%) total sperm count, 7% higher (95% CI: 0%; 14%) proportion of nonprogressive or immotile spermatozoa, 6% lower (95% CI: -11%; 0%) testes volume, 6% lower (95% CI: -12%; 1%) luteinizing hormone, 6% lower (95% CI: -12%; 1%) sex hormone-binding globulin and 5% lower (95% CI: -9%; 0%) testosterone levels compared with sons whose mothers had age at menarche at the same time as peers. Our study did not suggest that earlier maternal age at menarche was strongly associated with semen quality, testes volume or reproductive hormones in sons. However, the spline analyses indicated a potential inverted U-shaped association for sperm concentration and testes volume, and levels of sex hormone-binding globulin and testosterone. We found no strong evidence of mediation by timing of the sons' own pubertal development., Limitations, Reasons for Caution: There was a rather low participation rate in the Fetal Programming of Semen Quality Cohort and we tried to counter it by applying selection weights. Maternal age at menarche was recalled during pregnancy, which may introduce misclassification, most likely nondifferential. Inaccuracy of the sons' recalled pubertal development years after the event may result in underestimation of the possible mediating role of pubertal timing., Wider Implications of the Findings: Our findings may represent a degree of shared heritability of reproductive health or be a result of an underlying epigenetic profile or unknown shared environmental, cultural or dietary exposure, causing both altered age at menarche and impaired reproductive health outcomes in sons. However, the exact mechanism for the investigated association remains unknown., Study Funding/competing Interest(s): This article is part of the ReproUnion collaborative study, cofinanced by the European Union, Intereg V ÖKS (20200407). The FEPOS project was further funded by the Lundbeck Foundation (R170-2014-855), the Capital Region of Denmark, Medical doctor Sofus Carl Emil Friis and spouse Olga Doris Friis's Grant, Axel Muusfeldt's Foundation (2016-491), A.P. Møller Foundation (16-37), the Health Foundation and Dagmar Marshall's Fond. Additionally, this study received funding from Aarhus University. There are no competing interests., Trial Registration Number: N/A., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The discharge from hospital is an essential care transition for elderly people with chronic illness, specifically because the responsibility for treatment and care is transferred between locations and healthcare staff. To optimise the use of healthcare resources in a time of progressively shorter hospital admissions and increasingly streamlined hospital care, discharges are highlighted as important moments to be handled with caution. Yet, discharges are expected to be "early" and "quick" procedures to maintain a flow of patients through the hospital. In this qualitative article, we use ethnographic methods to investigate how this apparent contradiction unfolds in everyday discharge situations through the work of establishing discharge readiness in three medical wards in a middle-sized Danish hospital. We use the lens of infrastructure to help us see how elements like patient screens, screen meetings, clinical (and embodied) signs and community health care criteria are interrelated in the work of establishing discharge readiness of patients. By looking closely into specific discharge situations, we analyse the way care needs are defined and how care work is transferred, and we identify the inherent uncertainties for health care professionals, patients and relatives. We show how clinical signs take precedence over embodied experience, and how complex situations are reduced to workable problems to enable discharge., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The primary healthcare sector comprises various health services, including disease prevention at local level. Research shows that targeted primary healthcare services can prevent the development of acute complications and ultimately reduce the risk of hospitalisations. While interdisciplinary collaboration has been suggested as a means to improve the quality and responsiveness of personal care needs in preventive services, effective implementation remains a challenge. To improve the quality and responsiveness of primary healthcare and to develop initiatives to support the interdisciplinary collaboration in preventive services, there is a need to investigate the views of primary healthcare providers. The aim of this study was to investigate perceptions of preventive care among primary healthcare providers by examining their views on what constitutes a need for hospitalisation, and which strategies are found useful to prevent hospitalisation. Further, to explain how interdisciplinary collaboration can be supported with a view to providing person-centred care., Methods: Five focus group interviews were conducted with 27 healthcare providers, including general practitioners, social and healthcare assistants, occupational therapists, physiotherapists, home care nurses, specialist nurses and acute care nurses. Interviews were transcribed, and analysed with qualitative content analysis., Results: Three categories emerged from the analysis: 1) Mental and social conditions influence physical functioning and hospitalisation need, 2) Well-established primary healthcare services are important to provide person-centred care through interdisciplinary collaboration and 3) Interdisciplinary collaboration in primary healthcare services is predominantly focussed on handling acute physical conditions. These describe that the healthcare providers are attentive towards the influence of mental, social and physical conditions on the risk of hospitalisation, entailing a focus on person-centred care. Nevertheless, in the preventive services, interdisciplinary collaboration focusses primarily on handling acute physical conditions, which constitutes a barrier for interdisciplinary collaboration., Conclusions: By focusing on the whole person, it could be possible to provide more person-centred care through interdisciplinary collaboration and ultimately to prevent some hospitalisations. Stakeholders at all levels should be informed about the relevance of considering mental, social and physical conditions to improve the quality and responsiveness of primary healthcare services and to develop initiatives to support interdisciplinary collaboration., (© 2022. The Author(s).)

Problem framing is critical to developing risk prediction models because all subsequent development work and evaluation takes place within the context of how a problem has been framed and explicit documentation of framing choices makes it easier to compare evaluation metrics between published studies. In this work, we introduce the basic concepts of framing, including prediction windows, observation windows, window shifts and event-triggers for a prediction that strongly affects the risk of clinician fatigue caused by false positives. Building on this, we apply four different framing structures to the same generic dataset, using a sepsis risk prediction model as an example, and evaluate how framing affects model performance and learning. Our results show that an apparently good model with strong evaluation results in both discrimination and calibration is not necessarily clinically usable. Therefore, it is important to assess the results of objective evaluations within the context of more subjective evaluations of how a model is framed., (© 2021. The Author(s).)

Prostaglandin E 2 (PGE 2 ) promotes an immunosuppressive microenvironment in cancer, partly by signaling through four receptors (EP 1 , EP 2 , EP 3 , and EP 4 ) on T cells. Here, we comprehensively characterized PGE 2 signaling networks in helper, cytotoxic, and regulatory T cells using a phosphoproteomics and phosphoflow cytometry approach. We identified ~1500 PGE 2 -regulated phosphosites and several important EP 1–4 signaling nodes, including PKC, CK2, PKA, PI3K, and Src. T cell subtypes exhibited distinct signaling pathways, with the strongest signaling in EP 2 -stimulated CD8 + cells. EP 2 and EP 4 , both of which signal through G αs , induced similar signaling outputs, but with distinct kinetics and intensity. Functional predictions from the observed phosphosite changes revealed PGE 2 regulation of key cellular and immunological processes. Last, network modeling suggested signal integration between the receptors and a substantial contribution from G protein–independent signaling. This study offers a comprehensive view of the different PGE 2 -regulated phosphoproteomes in T cell subsets, providing a valuable resource for further research on this physiologically and pathophysiologically important signaling system.

Background: Prognostic markers for disease severity and identification of therapeutic targets in COVID-19 are urgently needed. We have studied innate and adaptive immunity on protein and transcriptomic level in COVID-19 patients with different disease severity at admission and longitudinally during hospitalization., Methods: Peripheral blood mononuclear cells (PBMCs) were collected at three time points from 31 patients included in the Norwegian SARS-CoV-2 cohort study and analysed by flow cytometry and RNA sequencing. Patients were grouped as either mild/moderate (n = 14), severe (n = 11) or critical (n = 6) disease in accordance with WHO guidelines and compared with patients with SARS-CoV-2-negative bacterial sepsis (n = 5) and healthy controls (n = 10)., Results: COVID-19 severity was characterized by decreased interleukin 7 receptor alpha chain (CD127) expression in naïve CD4 and CD8 T cells. Activation (CD25 and HLA-DR) and exhaustion (PD-1) markers on T cells were increased compared with controls, but comparable between COVID-19 severity groups. Non-classical monocytes and monocytic HLA-DR expression decreased whereas monocytic PD-L1 and CD142 expression increased with COVID-19 severity. RNA sequencing exhibited increased plasma B-cell activity in critical COVID-19 and yet predominantly reduced transcripts related to immune response pathways compared with milder disease., Conclusion: Critical COVID-19 seems to be characterized by an immune profile of activated and exhausted T cells and monocytes. This immune phenotype may influence the capacity to mount an efficient T-cell immune response. Plasma B-cell activity and calprotectin were higher in critical COVID-19 while most transcripts related to immune functions were reduced, in particular affecting B cells. The potential of these cells as therapeutic targets in COVID-19 should be further explored., (© 2021 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.)

Background: The pathogenesis of coronavirus disease 2019 (COVID-19) is still incompletely understood, but it seems to involve immune activation and immune dysregulation., Objective: We examined the parameters of activation of different leukocyte subsets in COVID-19-infected patients in relation to disease severity., Methods: We analyzed plasma levels of myeloperoxidase (a marker of neutrophil activation), soluble (s) CD25 (sCD25) and soluble T-cell immunoglobulin mucin domain-3 (sTIM-3) (markers of T-cell activation and exhaustion), and sCD14 and sCD163 (markers of monocyte/macrophage activation) in 39 COVID-19-infected patients at hospital admission and 2 additional times during the first 10 days in relation to their need for intensive care unit (ICU) treatment., Results: Our major findings were as follows: (1) severe clinical outcome (ICU treatment) was associated with high plasma levels of sTIM-3 and myeloperoxidase, suggesting activated and potentially exhausted T cells and activated neutrophils, respectively; (2) in contrast, sCD14 and sCD163 showed no association with need for ICU treatment; and (3) levels of sCD25, sTIM-3, and myeloperoxidase were inversely correlated with degree of respiratory failure, as assessed by the ratio of Pao 2 to fraction of inspired oxygen, and were positively correlated with the cardiac marker N-terminal pro-B-type natriuretic peptide., Conclusion: Our findings suggest that neutrophil activation and, in particular, activated T cells may play an important role in the pathogenesis of COVID-19 infection, suggesting that T-cell-targeted treatment options and downregulation of neutrophil activation could be of importance in this disorder., (Copyright © 2020. Published by Elsevier Inc.)

Eicosanoids modulate both innate and adaptive immune responses in Mycobacterium tuberculosis (Mtb) infection and have been suggested as possible Host Directed Therapy (HDT) targets, but more knowledge of eicosanoid dynamics in Mtb infection is required. We investigated the levels and ratios of eicosanoid mediators and their cellular sources, monocyte subsets and CD4 T cells in Tuberculosis (TB) patients with various clinical states of Mtb infection. Patients consenting to prospective enrolment in a TB quality registry and biorepository, 16 with pulmonary TB (before and at-end-of treatment), 14 with extrapulmonary TB and 17 latently infected (LTBI) were included. Plasma levels of Prostaglandin E2 (PGE2), Lipoxin A4 (LXA4), and Leukotriene B4 (LTB4) were measured by enzyme-linked immunosorbent assay. Monocyte subsets and CD4 T cells and their expression of Cyclooxygenase-2 (COX-2), Prostaglandin receptor EP2 (EP2), and 5-Lipoxygenase (5-LOX) were analyzed by flow cytometry with and without Purified Protein Derivate (PPD)-stimulation. Pulmonary TB patients had elevated levels of the anti-inflammatory mediator LXA4 at diagnosis compared to LTBI (p < 0.01), while levels of PGE2 and LTB4 showed no difference between clinical states of Mtb infection. LTB4 was the only mediator to be reduced upon treatment (p < 0.05), along with the ratio LTB4/LXA4 (p < 0.01). Pulmonary TB patients had higher levels of total monocytes at diagnosis compared to end-of-treatment and LTBI (both p < 0.05), and a relative increase in the classical monocyte subset. All monocyte subsets had low basal expression of COX-2 and 5-LOX, which were markedly increased upon PPD stimulation. By contrast, the expression of EP2 was reduced upon stimulation. CD4 T cells expressed low basal COX-2 activity that increased modestly upon stimulation, whereas their basal expression of 5-LOX was considerable. In conclusion, the level of eicosanoids in plasma seem to vary between clinical states of Mtb infection. Mediators in the eicosanoid system are present in monocytes and CD4 T cells. The expression of eicosanoids in monocytes are responsive to mycobacterial stimulation independent of Mtb disease state, but subsets are heterogeneous with regard to eicosanoid-mediator expression. Further exploration of eicosanoid mediators as targets for HDT in TB are warranted., (Copyright © 2020 Nore, Jørgensen, Dyrhol-Riise, Jenum and Tonby.)

Purpose: This paper describes the open cohort CROSS-TRACKS, which comprises population-based data from primary care, secondary care and national registries to study patient pathways and transitions across sectors while adjusting for sociodemographic characteristics., Participants: A total of 221 283 individuals resided in the four Danish municipalities that constituted the catchment area of Horsens Regional Hospital in 2012-2018. A total of 96% of the population used primary care, 35% received at least one transfer payment and 66% was in contact with a hospital at least once in the period. Additional clinical information is available for hospital contacts (eg, alcohol intake, smoking status, body mass index and blood pressure). A total of 23% (n=8191) of individuals aged ≥65 years had at least one potentially preventable hospital admission, and 73% (n=5941) of these individuals had more than one., Findings to Date: The cohort is currently used for research projects in epidemiology and artificial intelligence. These projects comprise a prediction model for potentially preventable hospital admissions, a clinical decision support system based on artificial intelligence, prevention of medication errors in the transition between sectors, health behaviour and sociodemographic characteristics of men and women prior to fertility treatment, and a recently published study applying machine learning methods for early detection of sepsis., Future Plans: The CROSS-TRACKS cohort will be expanded to comprise the entire Central Denmark Region consisting of 1.3 million residents. The cohort can provide new knowledge on how to best organise interventions across healthcare sectors and prevent potentially preventable hospital admissions. Such knowledge would benefit both the individual citizen and society as a whole., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Acute critical illness is often preceded by deterioration of routinely measured clinical parameters, e.g., blood pressure and heart rate. Early clinical prediction is typically based on manually calculated screening metrics that simply weigh these parameters, such as early warning scores (EWS). The predictive performance of EWSs yields a tradeoff between sensitivity and specificity that can lead to negative outcomes for the patient. Previous work on electronic health records (EHR) trained artificial intelligence (AI) systems offers promising results with high levels of predictive performance in relation to the early, real-time prediction of acute critical illness. However, without insight into the complex decisions by such system, clinical translation is hindered. Here, we present an explainable AI early warning score (xAI-EWS) system for early detection of acute critical illness. xAI-EWS potentiates clinical translation by accompanying a prediction with information on the EHR data explaining it.

Background: Hydrogen peroxide (H 2 O 2 ) is one of the delousing agents used to control sea lice infestations in salmonid aquaculture. However, some Lepeophtheirus salmonis populations have developed resistance towards H 2 O 2 . An increased gene expression and activity of catalase, an enzyme that breaks down H 2 O 2 , have been detected in resistant lice, being therefore introduced as a resistance marker in the salmon industry. In the present study the aim was to validate the use of catalase expression as a marker and to identify new candidate genes as additional markers to catalase, related to H 2 O 2 resistance in L. salmonis., Methods: A sensitive and an H 2 O 2 resistant laboratory strain (P0 generation, not exposed to H 2 O 2 for several years) were batch crossed to generate a cohort with a wide range of H 2 O 2 sensitivities (F2 generation). F2 adult females were then exposed to H 2 O 2 to separate sensitive and resistant individuals. Those F2 lice, the P0 lice and field-collected resistant lice (exposed to H 2 O 2 in the field) were used in an RNA sequencing study., Results: Catalase was upregulated in resistant lice exposed to H 2 O 2 compared to sensitive lice. This was, however, not the case for unexposed resistant P0 lice. Several other genes were found differentially expressed between sensitive and resistant lice, but most of them seemed to be related to H 2 O 2 exposure. However, five genes were consistently up- or downregulated in the resistant lice independent of exposure history. The upregulated genes were: one gene in the DNA polymerase family, one gene encoding a Nesprin-like protein and an unannotated gene encoding a small protein. The downregulated genes encoded endoplasmic reticulum resident protein 29 and an aquaporin (Glp1&#95;v2)., Conclusions: Catalase expression seems to be induced by H 2 O 2 exposure, since it was not upregulated in unexposed resistant lice. This may pose a challenge for its use as a resistance marker. The five new genes associated with resistance are put forward as complementary candidate genes. The most promising was Glp1&#95;v2, an aquaglyceroporin that may serve as a passing channel for H 2 O 2 . Lower channel number can reduce the influx or distribution of H 2 O 2 in the salmon louse, being directly involved in the resistance mechanism.

Rationale, Aims and Objectives: Patient involvement is increasingly recognized as a key component on the international health care agenda. This attention has brought a need for developing generic and standardized open-source methods, tools, and guidelines on how to systematically implement patient involvement initiatives in the clinical setting. The large-scale project the User-involving Hospital was initiated to implement two systematic methods for patient involvement at a Danish university hospital, but the required methods can only be implemented if embraced by the health professionals. This evaluation study aimed to explore the health professional perspective on the development and implementation of shared decision making (SDM) and user-led health care. Specifically, the objectives were to identify the most crucial preconditions for success and to translate the findings into practice recommendations., Method: The study was based on a simple questionnaire survey and a qualitative descriptive analysis of semistructured focus group interviews with representatives of 21 multidisciplinary clinical teams (nine interviews) and 18 health professional department managers (six interviews)., Results: Two years after the initiation of the User-involving Hospital, 13 out of 21 developed patient involvement initiatives were fully incorporated into clinical practice. Five domains were found significant for successful development and implementation of the patient involvement methods: the patients' perspectives, composition of multidisciplinary teams, bottom-up and skill building, support from management, and information sharing with colleagues., Conclusions: The findings draw attention to several significant factors for successful implementation of large-scale patient involvement initiatives in hospitals, including the importance of having both a top-down and bottom-up approach and of active listening to the patients' perspectives. On the basis of these findings, the study outlines four recommendations incorporating the five identified key domains, which may inspire future projects on systematic development and implementation of patient-involvement initiatives based on either shared decision making or user-led health care in the clinical setting., (© 2019 John Wiley & Sons, Ltd.)

Background: The timeliness of detection of a sepsis incidence in progress is a crucial factor in the outcome for the patient. Machine learning models built from data in electronic health records can be used as an effective tool for improving this timeliness, but so far, the potential for clinical implementations has been largely limited to studies in intensive care units. This study will employ a richer data set that will expand the applicability of these models beyond intensive care units. Furthermore, we will circumvent several important limitations that have been found in the literature: (1) Model evaluations neglect the clinical consequences of a decision to start, or not start, an intervention for sepsis. (2) Models are evaluated shortly before sepsis onset without considering interventions already initiated. (3) Machine learning models are built on a restricted set of clinical parameters, which are not necessarily measured in all departments. (4) Model performance is limited by current knowledge of sepsis, as feature interactions and time dependencies are hard-coded into the model., Methods: In this study, we present a model to overcome these shortcomings using a deep learning approach on a diverse multicenter data set. We used retrospective data from multiple Danish hospitals over a seven-year period. Our sepsis detection system is constructed as a combination of a convolutional neural network and a long short-term memory network. We assess model quality by standard concepts of accuracy as well as clinical usefulness, and we suggest a retrospective assessment of interventions by looking at intravenous antibiotics and blood cultures preceding the prediction time., Results: Results show performance ranging from AUROC 0.856 (3 h before sepsis onset) to AUROC 0.756 (24 h before sepsis onset). Evaluating the clinical utility of the model, we find that a large proportion of septic patients did not receive antibiotic treatment or blood culture at the time of the sepsis prediction, and the model could, therefore, facilitate such interventions at an earlier point in time., Conclusion: We present a deep learning system for early detection of sepsis that can learn characteristics of the key factors and interactions from the raw event sequence data itself, without relying on a labor-intensive feature extraction work. Our system outperforms baseline models, such as gradient boosting, which rely on specific data elements and therefore suffer from many missing values in our dataset., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Resistance towards deltamethrin (DMT) in the crustacean ectoparasite Lepeophtheirus salmonis (Caligidae) is a problem on fish farms lining the North Atlantic Ocean. Two Norwegian strains with different susceptibility towards DMT were crossed in the parental generation (P0), females from a sensitive strain were crossed with males from a resistant strain and vice versa. Individual susceptibility towards DMT was assessed in the second filial generation (F2). DMT resistance was only found in F2 descendants when the P0 females were from the resistant strain, pointing to maternal inheritance. Since maternal inheritance might be linked to the mitochondrial (mt) genome, the nucleotide sequences and the gene expressions of mt-genes were analysed. Twenty non-synonymous single nucleotide polymorphisms (SNPs) were identified in mt-transcripts from resistant F2 parasites, including SNPs in two cytochrome C oxidase subunits (COX1 and COX3) and two subunits of the NADH dehydrogenase complex (ND1 and ND5) previously linked to DMT resistance in the salmon louse. Differential expression analysis between the sensitive and resistant strain revealed strain effect in seven out of twelve mt-genes. The current study also show that DNA fragmentation (indicating apoptosis) was affected by DMT exposure in skeletal muscle tissue and that resistant parasites undergo less apoptosis than sensitive parasites.

Resistance towards antiparasitic agents in the salmon louse (Lepeophtheirus salmonis) is a widespread problem along the Norwegian coast, reducing treatments efficacies and slowing down the envisioned expansion of Norwegian salmon production. The present study was conducted in order to assess the efficacies of two of the most widely used anti-parasitic substances-azamethiphos and deltamethrin-as well as assessing the benefit of having a resistant genotype compared to being fully sensitive when exposed to one of these substances. Atlantic salmon were exposed to a mix of salmon lice copepodids from a fully sensitive, a double resistant and a multi-resistant strain. Once the lice reached pre-adult stages, one group was exposed to 100 μg/L azamethiphos for 60 minutes, the other to 2 μg/L deltamethrin for 30 minutes, and the last was kept in a seawater control. Detached lice were collected at a series of time points following exposure, and all lice (immobilized and surviving) were analysed for both pyrethroid (sensitive "S" and resistant "R") and azamethiphos (fully sensitive "SS", heterozygous resistant "RS" and fully resistant "RR") resistance markers. We found that the efficacies of deltamethrin on parasites with genotype S and R were 70.3 and 13.2%, respectively. The overall efficacy of the deltamethrin treatment was 32.3%. The efficacies of azamethiphos on parasites with genotype SS, RS and RR were 100, 80 and 19.1%, respectively. The overall efficacy of the azamethiphos treatment was 80.4%. Survival analyses revealed that the median survival time in deltamethrin-sensitive and-resistant parasites were 16.8 and >172 hours, respectively. The differences were even more pronounced in the azamethiphos-treated group, where SS, RS and RR parasites survived for 0.26, 6.6 and >172 hours, respectively. The substantial differences in survival between sensitive and resistant lice following treatment demonstrate the ability of medicinal treatments to drive genetic selection towards a much more resistant salmon lice population within a very short time span if there is no influx of sensitive genotypes.

Patient aggression is universally recognized as an important challenge in mental health care (MHC). Based upon a pragmatic exploration of the professional literature, we seek here to determine how negative emotional reactions of staff-including those conveyed in terms of fear, anger, and insult-may serve to exacerbate this serious impediment to safe and effective MHC. This is done using biological and evolutionary paradigms. Studies of patient aggression have tended to focus more on patient characteristics and behavior than on those of their caregivers. The authors suggest that patient aggression may be viewed as a response to "normal" interaction processes. The results of this investigation imply that the emotional reactions of staff may escalate the aggressive interaction by increasing the patient's perception of threat, and also, increase the probability of new incidents by creating a patient-staff relationship characterized by unsafety and mistrust. Mindfulness-based interventions are suggested as useful strategies to expand the staff's emotional awareness and increase emotional control., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Acetylcholinesterase (AChE) is an important enzyme in cholinergic synapses. Most arthropods have two genes (ace1 and ace2), but only one encodes the predominant synaptic AChE, the main target for organophosphates. Resistance towards organophosphates is widespread in the marine arthropod Lepeophtheirus salmonis. To understand this trait, it is essential to characterize the gene(s) coding for AChE(s). The full length cDNA sequences encoding two AChEs in L. salmonis were molecularly characterized in this study. The two ace genes were highly similar (83.5% similarity at protein level). Alignment to the L. salmonis genome revealed that both genes were located close to each other (separated by just 26.4 kbp on the L. salmonis genome), resulting from a recent gene duplication. Both proteins had all the typical features of functional AChE and clustered together with AChE-type 1 proteins in other species, an observation that has not been described in other arthropods. We therefore concluded the presence of two versions of ace1 gene in L. salmonis, named ace1a and ace1b. Ace1a was predominantly expressed in different developmental stages compared to ace1b and was possibly active in the cephalothorax, indicating that ace1a is more likely to play the major role in cholinergic synaptic transmission. The study is essential to understand the role of AChEs in resistance against organophosphates in L. salmonis.

Objectives: Sexually transmitted infections and unwanted pregnancies occur at high rates among youth. Understanding sexual behaviour is essential for planning and implementing future effective preventive interventions. The present study examines the sexual behaviour in the general Danish population aged 15-29 years using the core indicators recommended by the European Centre for Disease Prevention and Control., Methods: A nationwide cross-sectional study was conducted in Denmark among a random sample of 20 000 men and women in 2012. Respondents completed a web-based sexual behaviour questionnaire and data were linked to a nationally held demographic database. Core indicators for sexual behaviour frequency stratified by gender are presented as unweighted and weighted data after consideration of sociodemographic differences between respondents and non-respondents., Results: Response rate was 20.4%. Condoms were used at sexual debut by 69.9% of women and 62.3% of men, while 14.3% of women and 15.1% of men used no contraceptives at sexual debut. Half of the respondents used condom alone at the latest sexual encounter with a steady partner (women 51.8%, men 55.2%), while 10% used no contraceptives. Having a sexual encounter with a casual partner decreased the likelihood of using condoms (women 43.7%, men 49.5%) and increased the likelihood of using no contraceptives (women 14.8%, men 20.9%). Data on sexual behaviour characteristics showed only minor changes when weighted for non-response., Conclusions: The findings call for interventions addressing the use of appropriate contraception at sexual debut and at last sexual encounter; this seems particularly important when the sexual partner is a casual partner., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Acetylcholinesterase (AChE) is the primary target for organophosphates (OP). Several mutations have been reported in AChE to be associated with the reduced sensitivity against OP in various arthropods. However, to the best of our knowledge, no such reports are available for Lepeophtheirus salmonis. Hence, in the present study, we aimed to determine the association of AChE(s) gene(s) with resistance against OP. We screened the AChE genes (L. salmonis ace1a and ace1b) in two salmon lice populations: one sensitive (n=5) and the other resistant (n=5) for azamethiphos, a commonly used OP in salmon farming. The screening led to the identification of a missense mutation Phe362Tyr in L. salmonis ace1a, (corresponding to Phe331 in Torpedo californica AChE) in all the samples of the resistant population. We confirmed the potential role of the mutation, with reduced sensitivity against azamethiphos in L. salmonis, by screening for Phe362Tyr in 2 sensitive and 5 resistant strains. The significantly higher frequency of the mutant allele (362Tyr) in the resistant strains clearly indicated the possible association of Phe362Tyr mutation in L. salmonis ace1a with resistance towards azamethiphos. The 3D modelling, short term survival experiments and enzymatic assays further supported the imperative role of Phe362Tyr in reduced sensitivity of L. salmonis for azamethiphos. Based on all these observations, the present study, for the first time, presents the mechanism of resistance in L. salmonis against azamethiphos. In addition, we developed a rapid diagnostic tool for the high throughput screening of Phe362Tyr mutation using High Resolution Melt analysis.

Sea lice are copepod ectoparasites with vast reproductive potential and affect a wide variety of fish species. The number of parasites causing morbidity is proportional to fish size. Natural low host density restricts massive parasite dispersal. However, expanded salmon farming has shifted the conditions in favor of the parasite. Salmon farms are often situated near wild salmonid migrating routes, with smolts being particularly vulnerable to sea lice infestation. In order to protect both farmed and wild salmonids passing or residing in the proximity of the farms, several measures are taken. Medicinal treatment of farmed fish has been the most predictable and efficacious, leading to extensive use of the available compounds. This has resulted in drug-resistant parasites occurring on farmed and possibly wild salmonids., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Sexually transmitted infections (STIs) continue to be highly prevalent in young people. New understanding of sexual risk behaviour is essential for future preventive initiatives. Studies based on self-reported STI history indicate that gap length between sexual partnerships is an important determinant in STI transmission, but little is known about the impact of concurrent partnerships and short gap length. This study aimed to examine the significance of concurrent partnerships and short gap length between serially monogamous partnerships in Chlamydia trachomatis-infected individuals compared to the general population., Methods: A Danish cross-sectional study was conducted among individuals aged 15-29 years with a verified C. trachomatis infection and a sample of the background population. Participants answered a web-based questionnaire on sexual behaviour. Associations were identified in multivariate analyses., Results: In total, 36% of the included young adults reported that they had two or more partners within the last year. Concurrent partnerships were frequent (46%), and the gap length between serially monogamous partnerships tended to be short (median gap length, 64 days, interquartile interval (IQI) = 31, 122). A strong association was found between concurrent partnerships (odds ratio (OR) = 12.5, 95% confidence interval (CI) = 7.7-20.4), short gap length between serially monogamous partnerships (OR = 10.0, 95% CI = 5.7-17.4) and having a verified C. trachomatis infection., Conclusions: C. trachomatis infection was strongly associated with concurrent partnerships or short gap length between serially monogamous partnerships. These findings have considerable implications for public health policy. Both types of risk factors should be considered in future preventive interventions aiming to reduce the spread of C. trachomatis infections.

Background: The World Health Organization recommends vitamin A supplementation (VAS) at routine vaccination contacts after 6 months of age based on the assumption that it reduces mortality by 24%. The policy has never been evaluated in randomized controlled trials for its effect on overall mortality. We conducted a randomized double-blind trial to evaluate the effect of VAS with vaccines., Methods: We randomized children aged 6 to 23 months 1:1 to VAS (100000 IU if aged 6-11 months, 200000 IU if aged 12-23 months) or placebo at vaccination contacts in Guinea-Bissau. Mortality rates were compared in Cox proportional-hazards models overall, and by gender and vaccine., Results: Between August 2007 and November 2010, 7587 children were enrolled. Within 6 months of follow-up 80 nonaccident deaths occurred (VAS: 38; placebo: 42). The mortality rate ratio (MRR) comparing VAS versus placebo recipients was 0.91 (95% confidence interval 0.59-1.41) and differed significantly between boys (MRR 1.92 [0.98-3.75]) and girls (MRR 0.45 [0.24-0.87]) (P = .003 for interaction between VAS and gender). At enrollment, 42% (3161/7587) received live measles vaccine, 29% (2154/7587) received inactivated diphtheria-tetanus-pertussis-containing vaccines, and 21% (1610/7587) received both live and inactivated vaccines. The effect of VAS did not differ by vaccine group., Conclusions: This is the first randomized controlled trial to assess the effect of the policy on overall mortality. VAS had no overall effect, but the effect differed significantly by gender. More trials to ensure an optimal evidence-based vitamin A policy are warranted., (Copyright © 2014 by the American Academy of Pediatrics.)

Background: The effect of oral polio vaccine administered already at birth (OPV0) on child survival was not examined before being recommended in 1985. Observational data suggested that OPV0 was harmful for boys, and trials have shown that neonatal vitamin A supplementation (NVAS) at birth may be beneficial for boys. We set out to test this research question in a randomised trial., Methods: The trial was carried out at the Bandim Health Project, Guinea-Bissau. We planned to enrol 900 low-birth weight (LBW) boys in a randomised trial to investigate whether NVAS instead of OPV0 could lower infant mortality for LBW boys. At birth, the children were randomised to OPV (usual treatment) or VAS (intervention treatment) and followed for 6 months for growth and 12 months for survival. Hazard Ratios (HR) for mortality were calculated using Cox regression. We compared the individual anthropometry measurements to the 2006 WHO growth reference. We compared differences in z-scores by linear regression. Relative risks (RR) of being stunted or underweight were calculated in Poisson regression models with robust standard errors., Results: In the rainy season we detected a cluster of deaths in the VAS group and the trial was halted immediately with 232 boys enrolled. The VAS group had significantly higher mortality than the OPV0 group in the rainy season (HR: 9.91 (1.23 - 80)). All deaths had had contact with the neonatal nursery; of seven VAS boys enrolled during one week in September, six died within two months of age, whereas only one died among the six boys receiving OPV (p = 0.05). Growth (weight and arm-circumference) in the VAS group was significantly worse until age 3 months., Conclusion: VAS at birth instead of OPV was not beneficial for the LBW boys in this study. With the premature closure of the trial it was not possible to answer the research question. However, the results of this study call for extra caution when testing the effect of NVAS in the future., Trial Registration: http://www.clinicaltrials.gov NCT00625482. Registered 18 February 2008.

Interest in cytokines as markers for the function of the immune system is increasing. Methods quantifying cytokine concentrations are often subject to detection limits, which lead to non-detectable observations and censored distributions. When distributions are skewed, geometric mean ratios (GMRs) can be used to describe the relative concentration between two cytokines, and the GMR ratio (GMRR) can be used to compare two groups. The problem is how to estimate GMRRs from censored distributions.We evaluated methods, including simple deletion and substitution, in simulated and real data. One method applies Tobit directly to the censored difference between the two cytokine log-concentrations (Diff). However, censoring is correlated to the outcome and is therefore not independent. The correlation increases as the correlation between the two log-concentrations decreases. We propose a Tobit stacking method that uses clustered variance-covariance estimation allowing homogeneous (Stackc) or inhomogeneous (Stackh) variances. We compare it with direct estimation of the bivariate Tobit likelihood function (Bitobit) and multiple imputation. We assess sensitivity to inhomogeneity and non-normality. Simulations show that deletion and substitution are empirically biased and that Diff has an empirical bias, which increases as the correlation between the log-concentrations decreases. Estimates from multiple imputation, Stackh and Bitobit are almost identical. The estimates exhibit small empirical bias for both homogeneous and inhomogeneous normal distributions. For skewed mixture and heavy-tailed distributions, they perform reasonably well if censoring is less than 30%. We recommend these methods to estimate GMRRs. At least one of the methods is available in Stata, R or SAS., (Copyright © 2012 John Wiley & Sons, Ltd.)

Background: WHO recommends vitamin A supplementation (VAS) at vaccination contacts after six months of age. The effect of this recommendation on mortality has not been evaluated., Methods: We tested the effect of VAS at vaccination contacts on mortality in a randomised trial in Guinea-Bissau. In a subgroup within this trial we studied adverse reactions to VAS and whether VAS modified known adverse reactions to live and inactivated vaccines and general morbidity during the first month after supplementation overall and by sex. Children aged 6-17 months were randomised to VAS or placebo at the day of vaccination (day 0). We interviewed the caretaker, assessed the fontanel and measured temperature and local reaction at the injection site at home visits on day 1, 2, 3, 7, 14, 21, and 31. We defined systemic adverse reactions to inactivated and live vaccines as fever on day 1 and 2 and on 4-14 respectively. Clinical symptoms associated with increased intracranial pressure (ICP) on day 1 were considered possible adverse reactions to VAS., Results: In 1673 children VAS had no overall effect on clinical symptoms associated with increased ICP (Relative Risk(RR)=1.07 (95%CI: 0.85-1.35)). However, VAS was associated with such clinical symptoms in boys RR=1.38 (1.00-1.91)) but not in girls (p=0.03 for interaction between VAS and sex). VAS had no effect on fever after inactivated vaccines. VAS had no overall effect on fever after live vaccines (RR=0.86 (0.53-1.39)), but tended to reduce the prevalence of fever in boys (RR=0.58 (0.30-1.14)), but not in girls (RR=1.37 (0.66-2.84)) (p=0.09 for interaction between VAS and sex). VAS was associated with increased local reactions to measles vaccine in both sexes (RR=3.65 (1.20-11.12))., Conclusion: Adverse reactions were rare, mild and transient and may not in their own right cause concern. However, VAS caused sex-differential adverse reactions and may have sex-differential effects on adverse reactions to vaccines., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The World Health Organization (WHO) classifies Guinea-Bissau as having severe vitamin A deficiency (VAD). To date, no national survey has been conducted. We assessed vitamin A status among children in rural Guinea-Bissau to assess status and identify risk factors for VAD., Methods: In a vitamin A supplementation trial in rural Guinea-Bissau, children aged 6 months to 2 years who were missing one or more vaccines were enrolled, vaccinated and randomized to vitamin A or placebo. Provided consent, a dried blood spot (DBS) sample was obtained from a subgroup of participants prior to supplementation. Vitamin A status and current infection was assessed by an ELISA measuring retinol-binding protein (RBP) and C-reactive protein (CRP). VAD was defined as RBP concentrations equivalent to plasma retinol <0.7 μmol/L; infection was defined as CRP >5 ml/L. In Poisson regression models providing prevalence ratios (PR), we investigated putative risk factors for VAD including sex, age, child factors, maternal factors, season (rainy: June-November; dry: December-May), geography, and use of health services., Results: Based on DBS from 1102 children, the VAD prevalence was 65.7% (95% confidence interval 62.9-68.5), 11% higher than the WHO estimate of 54.7% (9.9-93.0). If children with infection were excluded, the prevalence was 60.2% (56.7-63.7). In the age group 9-11 months, there was no difference in prevalence of VAD among children who had received previous vaccines in a timely fashion and those who had not. Controlled for infection and other determinants of VAD, the prevalence of VAD was 1.64 (1.49-1.81) times higher in the rainy season compared to the dry, and varied up to 2-fold between ethnic groups and regions. Compared with having an inactivated vaccine as the most recent vaccine, having a live vaccine as the most recent vaccination was associated with lower prevalence of VAD (PR=0.84 (0.74-0.96))., Conclusions: The prevalence of VAD was high in rural Guinea-Bissau. VAD varied significantly with season, ethnicity, region, and vaccination status., Trial Registration: Clinicaltrials.gov NCT00514891.

Vitamin A supplementation (VAS) at birth was not associated with improved survival in a randomised, placebo-controlled trial in Guinea-Bissau. However, a negative sex-differential effect, which became evident after diphtheria-tetanus-pertussis (DTP) vaccination, was noted; among girls who had received DTP, VAS at birth was associated with two-fold higher mortality than placebo. The objective of the present study was to investigate the immunological effects of VAS at birth within a subgroup of participants in the randomised trial. Guided by the mortality results, we further explored whether VAS had a differential effect according to sex and DTP status. At 6 weeks after randomisation and supplementation, we measured differential leucocyte counts and TNF-α, interferon-γ, IL-10, IL-13 and IL-5 production in a whole-blood culture assay. A total of 471 children were included. VAS compared with placebo at birth was associated with a higher proportion of monocytes (relative risk ratio 1·26, 95 % CI 1·07, 1·49, P=0·04), while spontaneous TNF-α production was lower in the VAS group (geometric mean ratio 0·54, 95 % CI, 0·37, 0·78, P=0·001). Stratified analysis showed that VAS was associated with lower TNF-α and IL-10 production for girls without DTP and boys with DTP, resulting in significant three-way interactions between VAS, sex and DTP vaccination status (P=0·03 and P=0·04, respectively) for spontaneous TNF-α and IL-10 production. The results substantiate the potential role of VAS as an immunomodulatory intervention, which has different effects depending on concomitant health interventions and the sex of the recipient.

Introduction: Surveying sexual behaviour of the general population serves to identify key points of preventive interventions, monitor the effect and interpret changes in patterns of disease. Validated questionnaires describing sexual behaviour can be adapted to some extent from other countries, but national adaption, refinement and validation are needed due to cultural differences. The aim of this study was to identify factors influencing sexual risk behaviour among Danish adolescents with a view to designing and -initiating a national sexual behaviour surveillance programme in Denmark., Material and Methods: We conducted four semi-structured focus group interviews with a total of 19 sexually -experienced adolescents aged 18-23 years who attended a Danish Folk High School. Data were transcribed verbatim and analysed using qualitative description., Results: Four main categories of sexual risk behaviour were identified: 1) alcohol consumption which was associated with lack of condom use, 2) one-night stands after a night out partying, at festivals or on vacations, 3) low self-esteem which increased the risk of pushing one's personal boundaries, thus resulting in promiscuous sexual behaviour, 4) increased sexual experience which resulted in lack of condom use., Conclusion: This study identified four categories that may lead to unsafe sex. These results should be taken into consideration when planning future preventive programmes aiming to reduce sexually transmitted infections and unwanted pregnancies among adolescents and young adults., Funding: Not relevant., Trial Registration: Not relevant.

Within a neonatal vitamin A supplementation (VAS) trial, we investigated the effect of VAS on TNF-α, IL-10, IL-5 and IL-13 production after lipopolysaccharide, purified protein derivative (PPD) of Mycobacterium tuberculosis and phytohaemagglutinin stimulation using a whole blood culture protocol. We found that VAS recipients had lower unstimulated TNF-α concentrations than placebo recipients. In the present paper, we investigated whether the SNP TNF-α - 308, TNF-α - 238, IL-10 - 592, IL-10 - 1082 and toll-like receptor 4 (TLR4)+896 modified the effect of VAS on cytokine production. DNA and cytokine concentrations were available from 291 children. We found a significant interaction between TNF-α - 308 genotype and VAS for the unstimulated TNF-α production (Pinteraction = 0·04); among G homozygotes, TNF-α concentrations were significantly lower after VAS compared with placebo, whereas for A carriers, VAS did not appear to have any effect. For TNF-α - 238, there was a tendency towards an increase in PPD-stimulated TNF-α production after VAS for the G homozygotes, but the opposite tendency for A allele carriers (Pinteraction = 0·07). Stratification by sex revealed a significant VAS-genotype interaction for boys for TNF-α - 238. There was a borderline-significant three-way interaction (P = 0·05) between sex, VAS and TLR4+896 genotype. Although the present study had very limited representation of the genetic variation with potential for modification of the response to VAS, it adds to the efforts of untangling the diverse effects and impact of VAS.

Background: Vitamin A supplementation (VAS) decreases overall child mortality in low-income countries. For logistical reasons, VAS has been linked to routine childhood immunizations. However, several recent studies have indicated that VAS may increase mortality and morbidity from infectious diseases when given with the diphtheria-tetanus-pertussis (DTP) vaccine. The immunological effects of combining the 2 treatments are unknown., Methods: We studied the effect of treating C57BL/6 mice with VAS and DTP, 1 week prior to infection with Plasmodium berghei ANKA. The progression of disease was monitored through parasite load and time to death., Results: We found significantly higher levels of parasitaemia in VAS/DTP-treated mice than in control mice (crude geometric mean parasitaemia ratio 2.02 (1.08-3.76), p = 0.03). There was no effect of administering either VAS or DTP alone, indicating that the increase in parasitaemia was due to a synergistic effect of VAS and DTP (p for interaction = 0.02). The effect of VAS/DTP on levels of parasitaemia was modified by the specific parasite variant used. No effect was observed on time to death., Conclusion: Our results indicate that VAS/DTP can negatively influence the outcome of malaria infection in mice, adding to the concerns about simultaneous VAS and DTP administration to children in low-income, malaria endemic countries.

The disposition of STX in Atlantic salmon (Salmo salar) and Atlantic cod (Gadus morhua) was studied after intraperitoneal (IP) injection (5 microg STX/kg bm and 3.43 microg (3)H-STXeq/kg bw respectively), intravenous (IV) injection (5 microg STX/kg bm, only salmon) and waterborne exposure (50 microg STXeq/L, only salmon). Plasma concentrations in salmon were quantified using a receptor binding assay and cod tissues were analyzed using scintillation counting of tissue extracts and autoradiography of whole fish slices. The estimated elimination half-life (T(1/2)) after IV administration of STX in salmon was 102.6 min. The volume of distribution (Vz) was observed to be 467.2 mL/kg and the total body clearance (Cl(T)) was 3.2 mL/min/kg. Waterborne exposure clearly showed that salmon absorbed PSP toxins directly from the water. In cod, (3)H-STX was observed in gills, muscle, brain, liver and posterior kidney from 30 to 480 min. The lowest concentrations of (3)H-STX were found in brain and muscle, whereas posterior kidney contained the majority of the toxin. Autoradiograms confirmed the high levels of (3)H-STX in the kidneys, indicating that renal excretion was the main elimination route. Buildup of harmful levels in edible tissue is not very likely due to the low concentrations accumulated in muscle tissue and rapid excretion., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The World Health Organisation recommends vitamin A supplementation (VAS) to children aged 6 months to 5 years in low-income countries, and for logistic reasons, this has been linked to routine childhood immunizations. Observational studies suggest that VAS given with diphtheria-tetanus-pertussis (DTP) vaccine may increase mortality from non-targeted diseases. We investigated the non-targeted effect of pretreatment with VAS and DTP vaccine in a murine model of experimental cerebral malaria. Our a priori hypothesis was that VAS/DTP would aggravate the infection. We found that the effect of VAS and DTP depended on pathogenesis; VAS/DTP tended to increase parasitaemia and significantly depressed cytokine responses in mice, which developed cerebral malaria, but this was not seen in mice dying of anaemia. The divergent effect according to pathogenesis may help elucidate why VAS has divergent effects on different diseases in humans. Our results support the hypothesis that immunological effects of VAS/DTP may have detrimental implications for disease outcomes., (© 2010 The Authors. Scandinavian Journal of Immunology © 2010 Blackwell Publishing Ltd.)

The algal produced neurotoxins saxitoxin and domoic acid may have serious effects on marine life and can be responsible for the intoxication of for instance sea mammals, sea birds and fish. Given that farmed fish cannot escape algal blooms, they may be more susceptible to intoxication than wild stocks. In the present study, subclinical effects of saxitoxin and domoic on aggressive behaviour and monoaminergic systems in the brain of the rainbow trout (Oncorhynchus mykiss) were investigated. The resident-intruder test was used to measure aggression where only the resident fish were subjected to the toxins and analysed for monoamines and their metabolites. The resident-intruder test was carried out on two consecutive days. On day one basal aggression was measured in the four groups. On day two three of the groups were injected with subclinical doses of one of the following: saxitoxin (1.752 microg/kg bw), domoic (0.75 mg/kg bw) or 0.9% saline solution. This was performed 30 min prior to the aggression test. Handling stress and injection affected aggressive behaviour, cortisol and the serotonergic system in telencephalic brain regions. Cortisol levels were elevated in all of the injected groups when compared to the control group. An increase in serotonergic turnover was evident when all injected groups were pooled and compared to the control group. All together this suggests that the handling stress in connection with the injection was similar in all of the three injected groups. In contrast to both the undisturbed control group and the toxin-injected groups, the saline-injected group displayed a reduction in aggressive behaviour which was evident in increased attack latency. Furthermore the domoic injected group displayed more aggressive attacks towards their conspecifics than the saline-injected group. Consequently the two toxins appear to mask the stress induced alteration in aggressive behaviour. Monoamine levels and monoaminergic turnover could not be demonstrated to be directly affected by the two toxins at the given doses in the investigated brain regions (dorsal and ventral parts of telencephalon, optic tectum, locus coeruleus, raphe nucleus, molecular and granular layer of cerebellum). This could indicate that the toxins mediate aggressive behaviour either through other systems than the monoaminergic systems, such as neuroactive amino acids, or that the mediation occurs in other brain regions., (Copyright 2010 Elsevier B.V. All rights reserved.)

Background: We have proposed the hypothesis that the combination of vitamin A supplementation and diphtheria-tetanus-pertussis (DTP) vaccination may be associated with increased mortality in girls. Recent zinc/folic acid (FA) and iron supplementation trials did not find any beneficial effects on mortality. We reviewed the studies for evidence of a negative interaction between zinc/folic acid/iron and DTP vaccination in girls., Methods: Based on the published papers, we calculated age- and sex-specific mortality estimates. No vaccination status data were provided., Results: Both zinc/FA and iron seemed to have a sex- and age-differential effect, the effect being less beneficial in the youngest girls who are most likely to have DTP vaccine as their most recent vaccination., Conclusions: Like vitamin A, zinc/FA and iron may not benefit the youngest girls. The question is whether this is inherent in girls or due to an interaction with some environmental factor like DTP.

Neurotoxins from algal blooms have been reported to cause mortality in a variety of species, including sea birds, sea mammals and fish. Farmed fish cannot escape harmful algal blooms and their potential toxins, thus they are more vulnerable for exposure than wild stocks. Sublethal doses of the toxins are likely to affect fish behaviour and may impair cognitive abilities. In the present study, changes in the metabolic activity in different parts of the Atlantic salmon (Salmo salar) brain involved in central integration and cognition were investigated after exposure to sublethal doses of three algal-produced neurotoxins; saxitoxin (STX), brevetoxin (BTX) and domoic acid (DA). Fish were randomly selected to four groups for i.p. injection of saline (control) or one of the neurotoxins STX (10 microg STX/kg bw), BTX (68 microg BTX/kg bw) or DA (6 mg DA/kg bw). In addition, 14C-2-deoxyglucose was i.m. injected to measure brain metabolic activity by autoradiography. The three regions investigated were telencephalon (Tel), optic tectum (OT) and cerebellum (Ce). There were no differences in the metabolic activity after STX and BTX exposure compared to the control in these regions. However, a clear increase was observed after DA exposure. When the subregions with the highest metabolic rate were pseudocoloured in the three brain regions, the three toxins caused distinct differences in the respective patterns of metabolic activation. Fish exposed to STX displayed similar patterns as the control fish, whereas fish exposed to BTX and DA showed highest metabolic activity in subregions different from the control group. All three neurotoxins affected subregions that are believed to be involved in cognitive abilities in fish.

The general consensus is that brain serotonin (5-HT) inhibits feed intake in teleost fishes and other vertebrates. Dietary manipulations with the 5-HT precursor tryptophan (TRP) have, however, yielded contradictory effects on feed intake, while studies of the endocrine response to stress indicate that the effects of TRP-enriched feed are context dependent. A characteristic behavioural response to stress is a reduction in feed intake, and in the present study we investigated whether pre-treatment with TRP-enriched feed affected stress-induced changes in feeding behaviour in brown trout (Salmo trutta). After acclimatisation in observation aquaria, isolated fish were fed control or TRP-supplemented feed for 7 d, whereupon they were transferred to a novel environment, in which all fish were fed control feed. Transfer to a new environment resulted in decreased feeding in both the TRP pre-treated and the control-treated group. However, this decrease was more pronounced in the control-treated group. Previous experiments have concluded that stimulation of brain 5-HT systems by TRP enhancement does not affect feed intake in salmonid fishes, but in these studies food intake was observed in unstressed animals only. The present study suggests that pre-treatment with dietary TRP attenuates stress-induced anorexia. Hence, it appears that the effect of dietary manipulations of TRP on feeding behaviour is dependent on the stress levels experienced by experimental animals. These behavioural data are discussed in the context of the involvement of 5-HT in appetite regulation.

Colonoscopic screening for neoplasia was performed in a regional group of ulcerative colitis patients with a disease duration of greater than or equal to 15 years. A total of 121 patients, aged less than 80 years, were invited to participate, of whom 100 (83%) accepted colonoscopy, including biopsies in 15 standard locations of the entire colon, plus additional biopsies from all visible lesions. Unequivocal dysplasia was found in one patient with extensive colitis and a disease duration of 31 years. A polyp with highly differentiated adenocarcinoma was found in the sigmoid colon of a patient with intermittent rectum involvement, 37 years after the ulcerative colitis diagnosis had been made. Biopsy specimens from the remaining 98 patients showed no signs of dysplasia or cancer. Thus the frequency of pre-malignant or malignant changes is very low compared with the results of similar studies, and the rationale for general colonoscopic surveillance programmes for such patients is open to question.