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Measurements of pleural fluid biomarkers for rapid identification of complicated parapneumonic effusion (CPPE) are crucial for optimal management. Previous studies for biomarker evaluation were however based on pleura culture, not modern DNA technique. Lactate has not been thoroughly studied earlier as a potential biomarker in this regard. To evaluate whether the routine biomarkers pH, glucose, lactate dehydrogenase (LDH) measured in pleural fluid in a microbiological well characterised cohort could differentiate simple parapneumonic effusion (SPPE) from CPPE and if pleural fluid lactate could be of additional use in this discrimination. Pleural fluid prospectively collected from adult patients (n = 112) with PPE admitted to the Departments of Infectious Diseases (DIDs) at four Stockholm County hospitals were characterised microbiologically with bacterial culture and 16S rDNA sequencing, and biochemically with pH, glucose, LDH and lactate. Forty and seventy two patients were categorised as SPPE/CPPE. The median values between SPPE/CPPE differed significantly for all biomarkers with varying overlap. Receiver operating characteristics (ROC) curves showed the area under the curve (AUC) for pH 0.905 (CI 0.847–0.963), glucose 0.861 (CI 0.79–0.932), LDH 0.917 (CI 0.860–0.974) and lactate 0.927 (CI 0.877–0.977), corresponding to best cut-off levels and sensitivity/specificity for pH of 7.255, 0.819/0.9, glucose 5.35 mmol/L, 0.847/0.775, LDH 9.8 µcat/L, 0.905/0.825 and lactate 4.9 mmol/L, 0.875/0.85. To distinguish between SPPE/CPPE, pH and LDH performed well, but optimal cut-off values differed from earlier established recommendations. Pleura lactate had the largest AUC of the investigated biomarkers and may be used in the analyses of PPE-staging.

Background Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are the leading causes of hepatocellular carcinoma (HCC) worldwide. Limited data exist on surgical outcomes for NAFLD/NASH-related HCC compared with other HCC etiologies. We evaluated differences in clinicopathological characteristics and outcomes of patients undergoing surgical resection for NAFLD/NASH-associated HCC compared with other HCC etiologies. Methods Demographic, clinicopathological features, and survival outcomes of patients with surgically resected HCC were collected. NAFLD activity score (NAS) and fibrosis score were assessed by focused pathologic review in a subset of patients. Results Among 492 patients screened, 260 met eligibility (NAFLD/NASH [n = 110], and other etiologies [n = 150]). Median age at diagnosis was higher in the NAFLD/NASH HCC cohort compared with the other etiologies cohort (66.7 vs. 63.4 years, respectively, P = .005), with an increased percentage of female patients (36% vs. 18%, P = .001). NAFLD/NASH-related tumors were more commonly >5 cm (66.0% vs. 45%, P = .001). There were no significant differences in rates of lymphovascular or perineural invasion, histologic grade, or serum AFP levels. The NAFLD/NASH cohort had lower rates of background liver fibrosis, lower AST and ALT levels, and higher platelet counts (P Conclusions Patients with NAFLD/NASH-related HCC more commonly lacked liver fibrosis and presented with larger HCCs compared with patients with HCC from other etiologies. No differences were seen in rates of other high-risk features or survival. With the caveat of sample size and retrospective analysis, this supports a similar decision-making approach regarding surgical resection for NAFLD/NASH and other etiology-related HCCs.

Introduction: Encounters with children of foreign origin call for school nurses’ cultural competence during the health visits. This study aimed to investigate the statistical associations between the cultural constructs described by the Process of Cultural Competence in the Delivery of Healthcare Services (PCCDHS) model and whether school nurses’ cultural encounters, cultural knowledge, and cultural skill could statistically predict their cultural awareness. Methodology: Spearman correlation and hierarchical regression analyses were conducted using cross-sectional secondary data from 816 Swedish school nurses. The cultural constructs in the theoretical description of the PCCDHS model guided the selection and sorting of the items on cultural competence. Results: The constructs of cultural knowledge, cultural skill, cultural encounters, and cultural awareness were positively correlated with each other. However, becoming culturally aware was not statistically predicted by included cultural constructs ( R2 = 13.4, p = .06). Discussion: Despite the interrelations between the investigated cultural constructs of the PCCDHS model, understanding cultural awareness development requires further empirical testing.

Animal slurry contains plant nutrients such as nitrogen (N) that are essential for crop production. Inorganic slurry N is easily volatilised as ammonia after field application, reducing slurry fertiliser value and causing environmental problems. Ammonia emissions can be reduced by lowering slurry pH, rapid infiltration or incorporation of slurry into soil. This study investigated the effect of different combinations of slurry types and application strategies on ammonia emissions. The slurry types tested were untreated cattle slurry (CS), the liquid fraction from mechanical solid–liquid separation of cattle slurry (LF) and biogas digestate based mainly on cattle slurry (BD). The application strategies tested were trailing hoses, trailing shoes, trailing hose application of acidified slurry and slurry injection. Ammonia emissions after slurry application were measured using wind tunnels, with continuous measurements of ammonia concentrations in outgoing air. Comparisons were also made between measured ammonia emissions and emissions predicted by the ALFAM2 model. Cumulative ammonia emissions after 70 h from LF, CS and BD represented 23%, 29% and 32% of total ammoniacal nitrogen (TAN) applied. Trailing shoes and 50 mm deep injection slots reduced ammonia emissions by on average 17% and 37%, respectively, compared with trailing hoses. Slurry acidification resulted in an average reduction in ammonia emissions of 83%. The ALFAM2 model was reasonably accurate in predicting cumulative emissions (70 h). Accuracy in predicting emission dynamics was low in some cases, likely due to differences between wind tunnel measurements and open-air emissions and to model error.

To review the longitudinal trajectories – and the factors influencing their development – of mental health problems in children with neurodevelopmental disabilities. Systematic review methods were employed. Searches of six databases used keywords and MeSH terms related to children with neurodevelopmental disabilities, mental health problems, and longitudinal research. After the removal of duplicates, reviewers independently screened records for inclusion, extracted data (outcomes and influencing factors), and evaluated the risk of bias. Findings were tabulated and synthesized using graphs and a narrative. Searches identified 94,662 unique records, from which 49 publications were included. The median publication year was 2015. Children with attention deficit hyperactivity disorder were the most commonly included population in retrieved studies. In almost 50% of studies, trajectories of mental health problems changed by

We investigated the concordance between the Unyvero Hospitalized Pneumonia (HPN) application and quantitative culture for detection of bacterial pathogens from serial lower respiratory tract (LRT) specimens collected from the same subject. Comparison of results from HPN application and culture was evaluated using 69 LRT samples from 27 subjects, using two evaluation approaches. False positive detections by the HPN application was 29% (20/69) in Evaluation I vs 10% (7/68) in Evaluation II. Additional pathogens detected by the HPN application could be confirmed in many instances by culture positivity for the same organism from previous or subsequent samples from the same subject.

Following the outbreak of COVID-19 in 2020, the majority of European countries imposed lockdowns, whereas Sweden introduced comparatively moderate constraints. The Public Health Agency of Sweden stated that sports and physical activity could continue if conducted ‘safely’ and recommended outdoor activities. This article aims to identify new spatial practices and strategies developed by organised recreational sport providers (i.e. sport clubs, commercial providers) following the outbreak of the pandemic. Further, it identifies obstacles and opportunities for new spatial solutions, as well as possible long-term (lasting) effects of the strategies imposed. Also, it discusses these obstacles and opportunities in relation to contemporary sport facility challenge. The data draws upon 24 semi-structured interviews with sport coaches and leaders. All interviews were transcribed verbatim and analysed using a thematic analysis. The results suggest that most respondents show adaptability by moving their activities outdoors. Generally, for-profit organisations have been more innovative and adaptive. Obstacles for new spatial solutions include localisation, weather, (perceived) need of equipment, leadership, competing interests in public space, and notably the perception of what sport is. Positive examples of spatial adaptability show that there is a potential for sport providers to open up for different spatial solutions and more flexibility in relation to their activities, in order to ease the pressure on formal indoor (and, to some extent, outdoor) sport facilities while amending the perception of sport activities. Research methods The data draws upon 24 semi-structured interviews with sport coaches and leaders. All interviews were transcribed verbatim and analysed using a thematic analysis. Results and findings The results suggest that most respondents show adaptability by moving their activities outdoors. Generally, for-profit organisations have been more innovative and adaptive. Obstacles for new spatial solutions include localisation, weather, (perceived) need of equipment, leadership, competing interests in public space, and notably the perception of what sport is. Implications Positive examples of spatial adaptability show that there is a potential for sport providers to open up for different spatial solutions and more flexibility in relation to their activities, in order to ease the pressure on formal indoor (and, to some extent, outdoor) sport facilities while amending the perception of sport activities.

The current study investigated the structural validity and internal consistency of the Strengths and Stressors (SSF) questionnaire. The SSF is used in Swedish habilitation services to measure the positive and negative consequences that the fostering of a child with a developmental disability can have on family functioning in six domains: parent's feelings and attitudes, social life, family finances, relationship to the other parent, siblings, and professional support. The proposed six-factor model was tested with confirmatory factor analysis with data collected from 291 parents of children with developmental disabilities. The six-factor model had an acceptable fit according to most fit indices, but two items were non-significant. Overall, the internal consistency was acceptable or good. The SSF, with the proposed six-factor solution, can be a useful tool when assessing parental perspectives on the impacts of having a child with a developmental disability in clinical settings and research.

Background In the midst of the COVID-19 coronavirus pandemic, a new disease that affects children has arisen called multisystem inflammatory syndrome in children (MIS-C). Several research articles focusing on its medical aspects have been published, but very few have focused on nursing care. The aim of this study was therefore to describe the nursing status of children suffering from MIS-C and the experiences of registered nurses (RNs) in caring for these children in paediatric hospital inpatient care. Methods The study design includes both quantitative nursing clinical record data and qualitative interview data. Quantitative data from the clinical records were analysed using descriptive statistics. Qualitative data analysis of the interviews was conducted using both deductive and inductive approaches with content analysis. Results In total, 47 clinical records from children with MIS-C were investigated during January–March 2021. The mean age of the children was 8.8 years. Boys were more affected than girls. Challenges in children’s nursing status were related to circulation (fever and swelling), nutrition (great thirst and loss of appetite), pain, and psychosocial situations. When caring for children with MIS-C, nurses experienced “frustration over uncertainty of care”, “children’s illbeing” and “unavoidable procedures”. Conclusion This study contributes knowledge to the ongoing nursing care of children suffering from MIS-C. The results show many different areas of nursing focus, which challenges nurses and other disciplines within paediatric hospital care. One important factor when caring for these children was the use of a central venous line early in the care process, which improved the quality of care. Moreover, the care of children suffering from MIS-C demands resources and time from healthcare professionals, especially RNs, to meet caring needs and reduce illbeing.

Ammonia (NH 3) emissions from land-applied liquid manure (slurry) contribute to nitrogen deposition, acidification, and formation of fine particles in the atmosphere. Optimal management and field application techniques can reduce emission. A reduction in contact area between the slurry and the atmosphere is expected to reduce NH 3 emission. The objectives of this study were to develop a method for quantifying the exposed surface area (ESA) of field-applied slurry over time, and determine the degree to which ESA explains differences in NH 3 emission. Two experiments were conducted in which untreated, separated, and digested slurry was applied in bands on two different soils with spring oats stubble. Emission data were obtained from online wind tunnel measurements and slurry characteristics such as surface pH, viscosity, and particle size distribution were measured. The new ESA method relies on fluorescent dye added to the slurry prior to field application, followed by imaging. The results show that the ESA measurements can give new insight into the soil-slurry interactions after manure application, and this may help explain why some types of slurry and application techniques lead to successful abatement under some circumstances, but not under others. Furthermore, a pH-, TAN-, temperature-, and ESA-normalised NH 3 emission were estimated, helping idetify the effects of infiltration.

IntroductionThe use of proton therapy increases globally despite a lack of randomised controlled trials demonstrating its efficacy and safety. Proton therapy enables sparing of non-neoplastic tissue from radiation. This is principally beneficial and holds promise of reduced long-term side effects. However, the sparing of seemingly non-cancerous tissue is not necessarily positive for isocitrate dehydrogenase (IDH)-mutated diffuse gliomas grade 2–3, which have a diffuse growth pattern. With their relatively good prognosis, yet incurable nature, therapy needs to be delicately balanced to achieve a maximal survival benefit combined with an optimised quality of life.Methods and analysisPRO-GLIO (PROton versus photon therapy inIDH-mutated diffuse grade 2 and 3 GLIOmas) is an open-label, multicentre, randomised phase III non-inferiority study. 224 patients aged 18–65 years withIDH-mutated diffuse gliomas grade 2–3 from Norway and Sweden will be randomised 1:1 to radiotherapy delivered with protons (experimental arm) or photons (standard arm). First intervention-free survival at 2 years is the primary endpoint. Key secondary endpoints are fatigue and cognitive impairment, both at 2 years. Additional secondary outcomes include several survival measures, health-related quality of life parameters and health economy endpoints.Ethics and disseminationTo implement proton therapy as part of standard of care for patients withIDH-mutated diffuse gliomas grade 2–3, it should be deemed safe. With its randomised controlled design testing proton versus photon therapy, PRO-GLIO will provide important information for this patient population concerning safety, cognition, fatigue and other quality of life parameters. As proton therapy is considerably more costly than its photon counterpart, cost-effectiveness will also be evaluated. PRO-GLIO is approved by ethical committees in Norway (Regional Committee for Medical & Health Research Ethics) and Sweden (The Swedish Ethical Review Authority) and patient inclusion has commenced. Trial results will be published in international peer-reviewed journals, relevant conferences, national and international meetings and expert forums.Trial registration numberClinicalTrials.gov Registry (NCT05190172).

Survivin is a small protein that belongs to the inhibitor of apoptosis protein family and participates in cell division and apoptosis. It was actively studied in human cancers, inflammatory diseases and in autoimmune diseases. Here, we reveal that survivin takes part in epigenetic gene silencing by interaction with the polycomb repressive complex 2 (PRC2). PRC2 silences gene expression through tri-methylation of lysine 27 on histone 3 (H3K27). We detected differential expression of PRC2 core subunits in CD4+T cells with different survivin expression. ChIP-seq experiments indicated that survivin binds chromatin that overlap with the regions occupied by PRC2. ChIP-seq of H3K27 in CD4+T cells indicate that inhibition of survivin leads to a substantial increase in H3K27 tri-methylation by PRC2 in contrast to other histone modifications, which lends support to that survivin prevents PRC2 from functioning. Survivin binds peptides derived from PRC2 subunits EZH2, EED, SUZ12 and JARID2 in a peptide microarray that cover intersubunit interfaces, catalytic residues, and present binding sites for substrates, DNA, and regulatory proteins. Amino acid composition of the peptides has substantial predictive power for survivin interaction in the peptide microarray as determined by multilayer perceptron classification analysis. NMR experiments with 15N labelled survivin indicate that peptide colocalization does not entirely depend on binding mediated by short range interactions. These results indicate that survivin interacts with PRC2, preventing the methylation of H3K27 and specific gene silencing. This has transcriptional consequences and specific gene silencing.

The COVID-19 pandemic and its related measurements have challenged physical activity in various ways, ranging from closed fitness facilities to virtual curfews. Correspondingly, there is currently a rising scholarly interest in investigating how people have navigated their physical activity during the pandemic, and, especially, if physical activity has decreased or not. Accordingly, surveys and studies are rapidly accumulating. Therefore, the purpose of this literature review is to summarize, categorize, and map literature published before May 2021 on physical activity amid COVID-19.This study consists of a mixed methods explanatory sequential design, based on an outcome-oriented pragmatism of the middle. Firstly, a systematic literature review on Scopus was conducted, followed by a VOS-viewer bibliometric analysis. Subsequently, a focused literature review was written. The point of integration of methods was embedded. The systematic review resulted in 1,335 articles, which were used for two separate VOS-viewer visualizations. The illustrations reveal where research comes from, which journals have published most on physical activity during COVID-19, and how the research is globally cited. Furthermore, based on the review, three clear topical trends of research emerge; spatial transitions, frequencies of physical activity, and motivations to exercise during COVID-19. The bibliometric data demonstrates that research from only a few countries seem to be impactful, whereas the review portrays that conclusions in regard to whether physical activity has decreased or not lack agreement, possibly as a result of disclosing different definitions of physical activity.

The aim of this study was to use a 16S rDNA sequencing method in combination with conventional culture in patients with parapneumonic effusions (PPE) to evaluate the methods, study the microbiological spectrum, and examine the presence of bacteria within the different stages of PPE. Adults with community-acquired pneumonia (CAP) and PPE (n = 197) admitted to the Departments of Infectious Diseases at four hospitals in Stockholm County during 2011–2014 were prospectively studied. All patients underwent thoracentesis. Twenty-seven non-infectious pleural effusions were used as controls. The pleural samples were analyzed with culture, 16S rDNA sequencing, pH, glucose, and lactate dehydrogenase. Microbiological etiology was found in 99/197 (50%) of the patients with mixed infections in 20 cases. The most common pathogens were viridans streptococci (n = 37) and anaerobic bacteria (n = 40). Among the 152 patients with both methods performed, 26/152 (17%) and 94/152 (62%) had bacteria identified with culture and 16S rDNA sequencing respectively (p

Research question and purpose: Les Mills is a New Zealand-based fitness distributor with a community consisting of approximately 140.000 instructors worldwide who teach standardized workout routines. This paper aims to explore how the COVID-19 pandemic and related measurements, such as social distancing affect the everyday lives and professions of Les Mills International (LMI) group fitness instructors. The aim was met with the following research questions: RQ1: How are social distancing and social connectedness understood, and how do they condition LMI instructors’ understanding of their profession? RQ2: What do LMI instructors think about the #LesMillsUnited campaign to maintain a strong trainer community in the midst of the pandemic? RQ3: How do LMI instructors think that group fitness will change long term due to social distancing? Research methods: Using qualitative measures and a case-study-based approach, data were gathered through interviews with LMI-certified group fitness instructors. Seven semi-structured focused group discussions with fifteen group fitness instructors from different countries were conducted and audio recorded. The first round of virtual discussions took place in April 2020, and the follow-up talks in September 2020. A thematic analysis was employed to analyze the material. Results and findings: According to the participants, online classes as a means of upholding group fitness in times of social distancing is an insufficient substitute to face-to-face instructing, lacking social connectedness that is normally maintained through successful rituals or social scripts. Navigating “instructorhood” during the pandemic includes emotional labor where not only relationships to clients are challenged, but instructors also experience societal pressure to reinvent themselves as instructors. Implications: With no way of telling how long social distancing needs to be practiced, the group fitness industry is facing unprecedented challenges. Making sense of the group fitness profession currently preoccupies instructors who may now have to redefine to themselves how they can teach, and who for.

Background Participation of children with ID it is argued must be understood in relation to the fit with the environment. Since caregivers are a vital factor within the close environment of a child with intellectual disability, their perceptions are unequivocally important. Aims The main aim of this study is to describe the self-reported participation of children with ID and the perceptions of their primary caregivers. Both frequency of attendance and perceived importance of activity was measured with self-reported and proxy-reports. Methods & Procedures: A custom developed Picture my Participation (PmP) survey was utilised in an interview format with children with intellectual disability whilst their primary caregivers completed the survey independently. Results Overall, the perceptions of children with intellectual disabilities and of primary caregivers showed similarities regarding attendance and activities considered important. On group level, both children and primary caregivers perceived the child to have a high level of attendance ofFormal learning in school, Family mealtime, Interacting with family and Celebrations. An overall poor agreement in perceived frequency of attendance was found. However, in child-primary cargiver-dyads poor agreement in perceived frequency of attendance was found. Conclusions While primary caregivers and children’s ratings of attendance and selection of the most important activities appeared somewhat similar, there was a noted difference, in that primary caregivers’ were uniform in their selection, whilst there was a diversity in the selection of activities amongst children.

Food waste generation has received increasing attention in recent years. In this paper, we investigate the availability of information regarding food waste management on-board ships and describe how this information is communicated by companies operating passenger ships in the Baltic Sea. Furthermore, we summarize the aspects that influence efficient management of waste and identify pathways for food waste reduction on-board ships. The main three findings from this study are: (I) the information on waste handling at companies’ websites was to a large extent lacking. Food waste was mentioned in 22% of investigated ferry ship operator cases and in 32% of cruise ship operator cases. (II) In the interviews with environmental managers from two passenger ship companies, various aspects of food waste handling on-board ships were identified, which could be further grouped into technical, economic, management, legal and social categories. We suggest that the aspects of waste handling presented in this paper can serve as a framework for detection of the challenges and possibilities for different actors including shipping companies, ports and waste management agents. (III) The pathways towards efficient food waste handling may differ for individual ships, as it depends on vessel age, type of equipment and route schedules. The effort should be put in separating food waste from the rest of waste streams as it enables a clearer picture of the waste produced, increases the handling alternatives and may provide technological and economic benefits. Transparency and communication between the waste handling actors is the key in finding tailor-made solutions for treatment of ship-generated waste.

Material flow analysis is used to identify and quantify the flow of phosphorus (P) in ship-generated food waste and wastewater. Passenger, cruise, RoPax and cargo ships in the Baltic Sea were investigated in three scenarios: (1) if all waste is discharged to sea, (2) if all waste is disposed of ashore or (3) if the food waste fraction is disposed of ashore and wastewater is treated on-board. About 107 tonnes of P is generated annually in the waste streams, with highest contribution of approximately 62 tonnes (58%) from wastewater in the ship-category RoPax. Approximately 24 tonnes of P is contained in the food waste generated by the ships in the study. Forthcoming regulations over allowed nutrient concentrations in sewage will lead to 80% reduction in P from passenger ships and can reduce about 31 tonnes of P entering the Baltic Sea environment. If both sewage and grey water instead are offloaded in port reception facilities, about 76 tonnes of P-reduction to the sea can be reached. As most phosphorus recovery practices currently only are available on land it is recommended to direct the waste streams to port reception facilities for further treatment ashore.

Objective: Cervical cancer prevention shows a variability across Italian Regions unjustified by available evidence, increasing the health, economic and organizational burden. Evidence-based recommendations on topics not covered by international guidelines are needed to tackle existing inequalities. This article describes the rationale, methods, and process for development of the Multisociety Italian Guidelines for cervical cancer prevention. Methods: The Italian legislative framework requires guidelines to be consistent with methodological standards set by the National System for Guidelines (SNLG) of the National Institute of Health. Results: The nine scientific societies involved in cervical cancer prevention participated to the project, including clinicians, policy makers, methodologists, and researchers. Patients were involved as full voting panel members. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was adopted to assess the certainty of evidence collected by systematic reviews. The GRADE Evidenceto- Decision framework (EtD) was used to structure the appraisal of evidence and to formulate final recommendations. The EtD and a conflict-of-interests management policy were adopted to minimize the influence of competing interests. Discussion: Full transparency guided the reporting of each step of the process, to support the implementation of recommendations in each context and the future updating process. Considerations for subgroups, monitoring and evaluation of the implementation of recommendations and research priorities were also provided. A two-step review process by external experts and SNLG reviewers, prior to online publication, ensured the methodological robustness underlying final recommendations. Finally, to increase publication timeliness, guidelines are organised in chapters that group sets of related recommendations to be published independently.

To reach the International Maritime Organization, IMO, vision of a 50% greenhouse gas (GHG) emission reduction by 2050, there is a need for action. Good decision support is needed for decisions on fuel and energy conversion systems due to the complexity. This paper aims to get an overview of the criteria types included in present assessments of future marine fuels, to evaluate these and to highlight the most important criteria. This is done using a literature review of selected scientific articles and reports and the authors&rsquo, own insights from assessing marine fuels. There are different views regarding the goal of fuel change, what fuel names to use as well as regarding the criteria to assess, which therefore vary in the literature. Quite a few articles and reports include a comparison of several alternative fuels. To promote a transition to fuels with significant GHG reduction potential, it is crucial to apply a life cycle perspective and to assess fuel options in a multicriteria perspective. The recommended minimum set of criteria to consider when evaluating future marine fuels differ somewhat between fuels that can be used in existing ships and fuels that can be used in new types of propulsion systems.

Aim: The aim was to describe teenagers’ and parents’ perceptions of participation in treatment and their view of motivation within the context of obesity treatment. Methods: Qualitative interviews were conducted with 10 families (10 teenagers, aged 13 to 18 years and 6 parents) taking part in a family-based treatment model for childhood obesity. Data from interviews were processed with a phenomenographic analytic method. Results: The categories motivation promotion, motivation demotion, conditions for participation and supportive treatment interventions outline participants’ views on motivation and participation in the treatment of overweight/obesity. Motivation and opportunity for involvement in treatment is of great importance for parents and teenagers. Motivation was described as an important and necessary driving force for changing lifestyle behaviour. Conclusions: Future treatment interventions need to focus on further strengthening families’ participation and supporting motivation based on the experiences and suggestions that emerged in this study. For the health care sector, it is a challenge to develop comprehensive models that take families’ conditions into account and to involve them in the design of childhood obesity treatment.

Nasal decolonization has a proven effect on the prevention of severe Staphylococcus aureus infections and the control of methicillin-resistant S. aureus (MRSA). However, rising rates of resistance to antibiotics highlight the need for new substances for nasal decolonization. LTX-109 is a broad-spectrum, fast-acting bactericidal antimicrobial drug for topical treatment, which causes membrane disruption and cell lysis. This mechanism of action is not associated with cross-resistance and has a low propensity for development of resistance. In the present study, persistent nasal MRSA and methicillin-sensitive S. aureus (MSSA) carriers were treated for 3 days with vehicle or with 1%, 2%, or 5% LTX-109. A significant effect on nasal decolonization was observed already after 2 days of LTX-109 treatment in subjects treated with 2% or 5% LTX-109 compared to vehicle ( P ≤ 0.0012 by Dunnett′s test). No safety issues were noted during the 9-week follow-up period. Minimal reversible epithelial lesions were observed in the nasal cavity. The systemic exposure was very low, with a maximum concentration of drug in plasma ( C max ) at 1 to 2 h postdosing (3.72 to 11.7 ng/ml). One week after treatment initiation, LTX-109 was not detectable in any subject. Intranasal treatment of S. aureus with LTX-109 is safe and reduces the bacterial load already after a single day of treatment. Hence, LTX-109 has potential as a new and effective antimicrobial agent with a low propensity of resistance development that can prevent infections by MSSA/MRSA during hospitalization. (This study has been registered at ClinicalTrials.gov under registration no. NCT01158235.)

The Paris Agreement aims to hold the increase in the global average temperature to well below 2°C above pre-industrial levels (and pursue efforts to limit it to 1.5°C), but does not refer specifically to greenhouse gas emissions from the international maritime transport sector. This Report outlines the findings of a project commissioned by the Nordic Council of Ministers, focusing on opportunities for Nordic countries to achieve a transition to low-carbon shipping at national, regional and global scales. It is informed by discussions at the World Maritime University in Malmö in December 2016 between representatives of governments, businesses, NGOs and the research community. The Report presents a low-carbon roadmap for shipping with actions and outcomes concerning low-carbon technology, ship operations, finance, public policy, and public-private partnerships.

The regionalized Global Energy Transition model has been modified to include a more detailed shipping sector in order to assess what marine fuels and propulsion technologies might be cost-effective by 2050 when achieving an atmospheric CO2 concentration of 400 or 500 ppm by the year 2100. The robustness of the results was examined in a Monte Carlo analysis, varying uncertain parameters and technology options, including the amount of primary energy resources, the availability of carbon capture and storage (CCS) technologies, and costs of different technologies and fuels. The four main findings are (i) it is cost-effective to start the phase out of fuel oil from the shipping sector in the next decade; (ii) natural gas-based fuels (liquefied natural gas and methanol) are the most probable substitutes during the study period; (iii) availability of CCS, the CO2 target, the liquefied natural gas tank cost and potential oil resources affect marine fuel choices significantly; and (iv) biofuels rarely play a major role in the shipping sector, due to limited supply and competition for bioenergy from other energy sectors.

The combined effort of reducing the emissions of sulphur dioxide, nitrogen oxides and greenhouse gases to comply with future regulations and reduce impact on climate change will require a significant change in ship propulsion. One alternative is to change fuels. In this study we compare the life cycle environmental performance of liquefied natural gas (LNG), liquefied biogas (LBG), methanol and bio-methanol. We also highlight a number of important aspects to consider when selecting marine fuels. A transition to use of LNG or methanol produced from natural gas would significantly improve the overall environmental performance. However, the impact on climate change is of the same order of magnitude as with use of heavy fuel oil. It is only the use of LBG and bio-methanol that has the potential to reduce the climate impact. The analysis did not show any significant differences in environmental performance between methane and methanol when produced from the same raw materials, but the performance of the methanol engines are yet to be validated.

The upcoming stricter emission control area (ECA) regulations on sulphur and nitrogen oxides (NOX) emissions from shipping can be handled by different strategies. In this study, three alternatives complying with the ECA regulations for sulphur as well as Tier III for NOX are presented and compared using life cycle assessment. None of the three alternatives will significantly reduce the life cycle impact on climate change compared to heavy fuel oil (HFO). However, all alternatives will reduce the impact on particulate matter, photochemical ozone formation, acidification and terrestrial eutrophication potential. The assessment also highlighted two important regulatory aspects. Firstly, the need to regulate the ammonia slip from use of selective catalytic reduction (SCR) and secondly the need to regulate the methane slip from LNG engines. In addition, an analysis of the use of SCR in Swedish waters is presented showing that SCRs have been used on a number of ships already giving significantly reduced NOX emissions.

Increased energy efficiency will be paramount in mitigating CO2 emissions from shipping. Paradoxically, previous research has shown that a substantial amount of measures, that typically increase energy efficiency, should be cost-efficient to implement. This is often explained in literature in terms of barriers in markets, institutions and organizations. This article is the first of a series of articles from a joint industry project aiming at understanding good energy management practices. It explores barriers to energy efficiency in shipping through a case study of a short sea shipping company in their process to improve their approach to managing work with energy efficiency. An action research approach was chosen to contribute to better practice as well as knowledge in the research community. The study shows that work with energy efficiency was not straightforward, and several challenge areas could be discerned: project management capabilities, ship-shore communication, division of responsibilities, access to performance measurements, and competence in energy efficiency. The action research approach gave rich insight and new perspectives were gained on the traditional barrier discourse.

Improved understanding of ship energy use can be a crucial part of the process of increasing ship energy efficiency. In this paper, the methodology of energy analysis is applied to ship energy systems in order to showcase the benefits of such methodology. Data from one year of operations of a case study ship were used, together with mechanistic knowledge of ship systems, in order to evaluate the different energy flows. The identification of main producers, consumers and waste flows, allowed by the application of the method, leads to the suggestion of a number of possible improvements guided by the improved knowledge of the ship's energy system.

Short sea shipping is facing harder requirements on exhaust emissions in the coming years as stricter regulations are enforced in some regions of the world. In addition, shortage of conventional fuels as well as restrictions on greenhouse gas emissions makes the search for new fuels of interest. The objective of this article is to assess important characteristics to evaluate when selecting fuels for short sea shipping. The following four criteria are considered: (1) local and regional environmental impacts, (2) overall environmental impact, (3) infrastructure and (4) fuel cost and competition with other transport modes. Special focus is put on environmental impact, and life cycle assessment is used for the environmental assessment. The fuels compared in this study are heavy fuel oil, marine gas oil, biomass-to-liquid fuel, rapeseed methyl ester, liquefied natural gas and liquefied biogas. This study shows that liquefied natural gas will reduce the local and regional environmental impacts more relative to the other fuels investigated here. Furthermore, liquefied biogas is found to be the most preferable if all environmental impact categories are considered. This study also highlights the importance to consider other impact categories for short sea shipping compared to deep sea shipping and shows that NOX emission is the dominant contributor to all assessed environmental impact categories with local and regional impacts.

The IMO Ship Energy Efficiency Management Plan (SEEMP) is the sole international regulatory instrument expected to affect rising CO2 emissions from shipping in the short-term. In this article, we discuss present gaps in the SEEMP guidelines through a comparison with the international standard for energy management systems, ISO 50001, and with the International Safety Management (ISM) Code, which sets requirements for safety management systems in shipping companies. We show that the SEEMP lacks crucial features found in typical management system standards, such as requirements on policy and management reviews. Moreover, best-practice in the form of the ISO 50001 addresses important aspects, such as monitoring, energy auditing, design, and procurement processes in much more detail. In the context of previous research on these instruments and on energy efficiency in general, we argue that these gaps may be detrimental to the success of the SEEMP, both from the societal perspective of CO2 abatement and from the perspective of companies’ success in energy management. This requires further attention by academia, policy-makers and industry.

Children born preterm are at risk of neonatal complications but the long-term consequences for everyday functioning is not well known. The study aimed to identify patterns of everyday functioning in preschool children born preterm and at term in relation to perinatal data, neonatal risk factors, behaviour, and socioeconomic status. Registry data and data from parent rated questionnaires were collected for 331 children.A person-oriented approach with a cluster analysis was used.A seven cluster solution explained 65.91% of the variance. Most children (n=232) showed patterns of strong everyday functioning. A minority of the children (n=99), showed diverse patterns of weak everyday functioning. Perinatal characteristics, neonatal risk factors and socio-economics did not predict cluster group membership. Children born preterm were represented in all clusters.Most preschool children are perceived by their parents with strong everyday functioning despite being born preterm. However small groups of children are, for various reasons, perceived with weak functioning, but preterm birth is not the sole contributor to patterns of weak everyday functioning. More critical for all children's everyday functioning is probably the interaction between individual factors, behavioural factors and contextual factors. To gain a broader understanding of children's everyday functioning. Child Health Services need to systematically consider aspects of body function, activity and in addition participation and environmental aspects.

In a world with increased pressure on reducing fuel consumption and carbon dioxide emissions, the cruise industry is growing in size and impact. In this context, further effort is required for improving the energy efficiency of cruise ship energy systems. In this paper, we propose a generic method for modelling the power plant of an isolated system with mechanical, electric and thermal power demands and for the optimal load allocation of the different components that are able to fulfil the demand. The optimisation problem is presented in the form of a mixed integer linear programming (MINLP) problem, where the number of engines and/or boilers running is represented by the integer variables, while their respective load is represented by the non-integer variables. The individual components are modelled using a combination of first-principle models and polynomial regressions, thus making the system nonlinear. The proposed method is applied to the load-allocation problem of a cruise ship sailing in the Baltic Sea, and used to compare the existing power plant with a hybrid propulsion plant. The results show the benefits brought by using the proposing method, which allow estimating the performance of the hybrid system (for which the load allocation is a non-trivial problem) while also including the contribution of the heat demand. This allows showing that, based on a reference round voyage, up to 3% savings could be achieved by installing the proposed system, compared to the existing one, and that a NPV of 11kUSD could be achieved already 5years after the installation of the system.

This book focuses on the interaction between shipping and the natural environment and how shipping can strive to become more sustainable. Readers are guided in marine environmental awareness, environmental regulations and abatement technologies to assist in decisions on strategy, policy and investments. You will get familiar with possible paths to improve environmental performance and, in the long term, to a sustainable shipping sector, based on an understanding of the sources and mechanisms of common impacts. You will also gain knowledge on emissions and discharges from ships, prevention measures, environmental regulations, and methods and tools for environmental assessment. In addition, the book includes a chapter on the background to regulating pollution from ships. It is intended as a source of information for professionals connected to maritime activities as well as policy makers and interested public. It is also intended as a textbook in higher education academic programmes.