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OBJECTIVE: The aim of this study was to assess the association between occupational biomechanical exposures and the occurrence of surgical treatment for subacromial impingement syndrome (SIS). METHODS: A cohort of 220 295 male constructions workers who participated in a national occupational health surveillance program (1971-1993) were examined prospectively over a 16-year follow-up period (2001-2016) for surgically treated SIS. Worker job title, smoking status, height, weight, and age were registered on health examination. Job titles were mapped to 21 occupational groups based on tasks and training. A job exposure matrix (JEM) was developed with exposure estimates for each occupational group. Surgical cases were determined through linkage with the Swedish national in- and outpatient registers. Poisson regression was used to assess the relative risks (RR) for each biomechanical exposure. RESULTS: The total incidence rate of surgically treated SIS over the 16-year observation period was 201.1 cases per 100 000 person-years. Increased risk was evident for workers exposed to upper-extremity loading (push/pull/lift) (RR 1.45-2.30), high hand grip force (RR 1.47-2.23), using handheld tools (RR 1.52-2.09), frequent work with hands above shoulders (RR 1.62-2.11), static work (RR 1.77-2.26), and hand-arm vibration (RR 1.78-2.13). There was an increased risk for SIS surgery for all occupational groups (construction trades) compared with white-collar workers (RR 1.56-2.61). CONCLUSIONS: Occupational upper-extremity load and posture exposures were associated with increased risk for surgical treatment of SIS, which underlines the need for reducing workplace exposures and early symptom detection in highly exposed occupational groups.

BACKGROUND: To regain the ability to walk is one of the most commonly stated goals for people who have had a stroke due to its importance in everyday life. Walking ability affects patients’ mobility, self-care, and social lives. Constraint-induced movement therapy (CIMT) is known to be effective in improving upper extremity outcomes post-stroke. However, there is insufficient evidence regarding its efficacy in improving lower extremity outcomes.AIM: To investigate whether a highly intensive CIMT for lower extremity (LE-CIMT) function post-stroke can improve motor function, functional mobility, and walking ability. Furthermore, it also aimed to investigate whether age, gender, stroke type, more-affected side, or time after stroke onset affect the efficacy of LE-CIMT on walking ability outcomes. DESIGN: Longitudinal cohort study. SETTING: Outpatient clinic in Stockholm, Sweden. POPULATION: A total of 147 patients mean age 51 years (68% males; 57% right-sided hemiparesis), at the sub-acute or chronic phases post-stroke who had not previously undergone LE-CIMT. METHODS: All patients received LE-CIMT for 6 hours per day over 2 weeks. The Fugl-Meyer Assessment (FMA) of the lower extremity, Timed Up and Go (TUG) test, Ten-Meter Walk Test (10MWT), and six-Minute Walk Test (6MWT) were used to assess functional outcomes before and directly after the 2-week treatment was complete as well at 3-month post-intervention. RESULTS: Compared to baseline values, FMA (P

Ultrasonic echolucent carotid intima-media (IM) complex and accelerated progression of carotid intima mediathickness (cIMT) have both separately been shown to predict future cardiovascular events. The aim of this studywas to evaluate if the echogenicity of the IM-complex is associated with the 3-year progression of cIMT. B-modeultrasound images captured at baseline and 3-year follow-up in the ‘Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention’ (VIPVIZA) trial were included (n: 3154). The bilateral mean cIMT and IM-echogenicity by greyscale median (GSM) were measured in the common carotid artery. Associations between IM-GSM at baseline and the 3-year cIMT progression were investigated using linear regression models for the whole population and stratified by sex, age and VIPVIZA study group (intervention versus control). In addition, adjusted analyses for confounding factors were performed. Unadjusted analysis showed that decreased IM-GSM at baseline was associated with increased progression of cIMT (p < 0.001). Stratified by age, the association was significant among 40 (p < 0.001) and 60 years old (p < 0.001). The association was statistically significant in both sexes and on comparison of VIPVIZA study subgroups. Adjustments for confounding factors did not alter the estimated relationship between IM-GSM and cIMT progression. Echolucent carotid intima media at baseline associates with increased 3-year cIMT progression among an asymptomatic, middle-aged population. Echogenicity of the intima media may identify individuals at risk for accelerated vascular aging.

We compared hand activity and force ratings in women and men doing identical hand-intensive work tasks. Musculoskeletal disorders are more common in women and hand-intensive work leads to an increased risk of these disorders. Knowledge of the gender influence in the rating of work exposure is lacking. The aim of this study was to investigate whether women and men performing identical hand-intensive work tasks were equally rated using hand activity and normalized peak force levels with the Hand Activity Threshold Limit Value®. Fifty-six workers participated, comprising 28 women–men pairs. Four observers—two woman–man pairs—were also involved. Self-ratings and observers’ ratings of hand activity and force level were collected. The results of these ratings showed no significant gender differences in self-rated hand activity and force, as well as observer-rated hand activity. However, there was a significant gender difference in the observer-rated force, where the women were rated higher (mean (SD): women 3.9 (2.7), men 3.1 (1.8) (p = 0.01)). This difference remained significant in the adjusted model (p = 0.04) with grip strength and forearm–finger anthropometrics. The results provide new insights that observers’ estimates of force can be higher in women compared with men in the same work tasks. Force should be further investigated and preferably compared to objective measurements.

Objectives Chronic pain patients often suffer in multiple locations. In health care, examinations of bodily pain usually do not include questions about temporomandibular disorders (TMD); hence TMD symptoms and potential comorbidities are not regularly assessed. Therefore, the primary aim was to evaluate the prevalence of TMD in patients referred to a pain rehabilitation clinic, and the secondary aim was to evaluate possible factors associated with TMD symptoms. Methods Consecutive chronic pain patients referred to the Pain Rehabilitation Clinic at the Umeå University Hospital in Sweden were included. TMD symptoms were assessed using three valid screening questions – 3Q/TMD. Pain sites, emotional distress, kinesiophobia, and demographics were obtained from the Swedish Quality Registry for Pain Rehabilitation. Results In total, 188 (144 women) chronic pain patients (mean age 41.8 years) were included. Of these, 123 (96 women) answered affirmatively to at least one of the 3Q/TMD. The relative risk of TMD symptoms among the patients with chronic pain, in comparison to the general population, was 7.1 (95% CI 5.9–8.4). Age was the only independent variable associated with TMD among the patients (p = 0.018). Conclusions The prevalence of TMD symptoms was higher in a chronic pain population compared to the general population. The 3Q/TMD questionnaire could be a suitable screening tool at pain rehabilitation clinics to identify patients for further examination of involvement of pain in the trigeminal region. Our results reinforce the clinical importance of paying attention to concurrent widespread pain and local TMD symptoms.

The prevalence of orofacial pain is on the rise and especially in women, thus indicating an increasing gender difference in orofacial pain., Although a fluctuating pattern of orofacial pain across the life span has been proposed, data on its natural course are lacking. The longitudinal course of orofacial pain in the general population was evaluated using data from routine dental check-ups at all Public Dental Health services in Västerbotten, Sweden. In a large population sample, 2 screening questions were used to identify individuals with pain once a week or more in the orofacial area. Incidence and longitudinal course of orofacial pain were evaluated using annual data for 2010 to 2017. To evaluate predictors for orofacial pain remaining over time, individuals who reported pain on at least 2 consecutive dental check-ups were considered persistent. A generalized estimating equation model was used to analyze the prevalence, accounting for repeated observations on the same individuals. In total, 180,308 individuals (equal gender distribution) were examined in 525,707 dental check-ups. More women than men reported orofacial pain (odds ratio 2.58, 95% confidence interval [CI] 2.48-2.68), and there was a significant increase in the prevalence of reported pain from 2010 to 2017 in both women and men. Longitudinal data for 135,800 individuals were available for incidence analysis. Women were at higher risk of both developing orofacial pain (incidence rate ratio 2.37; 95% CI 2.25-2.50) and reporting pain in consecutive check-ups (incidence rate ratio 2.56; 95% CI 2.29-2.87). In the northern Swedish population studied, the prevalence of orofacial pain increases over time and more so in women, thus indicating increasing differences in gender for orofacial pain.

BACKGROUND CONTEXT: Degenerative changes due to cervical spondylosis (CS) can detrimentally affect work ability and quality of life yet understanding of how physical exposure affects disease progression is limited. PURPOSE: To assess the associations between occupational physical exposures and occurrence of surgically treated cervical spondylosis (ST-CS) and early exit from the labour market via disability pension. STUDY DESIGN/SETTING: Prospective register study with 20 year follow-up period. PATIENT SAMPLE: Swedish construction workers participating in a national health surveillance project conducted between 1971-1993. OUTCOME MEASURES: Surgically treated cervical spondylosis (ST-CS) and early labour market exit at a minimum rate of 25% time on disability pension. METHODS: Associations between occupational physical exposures (job exposure matrix) and subsequent ST-CS (National Hospital in-patient register) and early labour market exit via disability pension (Swedish Social Insurance Agency register) were assessed in a cohort of male construction workers (n=237,699). RESULTS: A total of 1381 ST-CS cases were present and a 20-year incidence rate of 35.1 cases per 100,000 person years (95% confidence interval (CI) 33.2-36.9). Increased relative risk (RR) for ST-CS was found for workers exposed to non-neutral (RR 1.40, 95% CI 1.15-1.69) and awkward neck postures (1.52, 1.19-1.95), working with the hands above shoulder height (1.30, 1.06-1.60), and high upper extremity loading (1.35, 1.15-1.59). Increased risk was also present for workers who reported frequent neck (3.06, 2.18-4.30) and upper back (3.84, 2.57-5.73) pain in the 12 months prior to survey. Among workers with elevated arm exposure, higher risk was seen in those who also had more frequent neck pain. ST-CS cases took early retirement more often (41.3%) and at a younger age (53 years) than the total study cohort (14.8% and 56 years of age, respectively). CONCLUSIONS: Occupational exposure to non-neutral neck postures, work with hands above shoulders and high loads born through the upper extremities increased the risk for ST-CS and early retirement due to disability. Decreasing postural and load exposure is salient for primary, secondary, and tertiary prevention of CS. Neck pain was shown to be a prognostic factor for ST-CS, which stresses the importance of acting early and taking preventative action to reduce workplace exposure, and the need for systematic medical check-ups within primary or occupational care to mitigate disease progression and early labour market exit due to disability.

Prostate cancer surgery risks erectile problems and incontinence for the patient. An instrument for guiding surgeons to avoid nerve bundle damage and ensure complete cancer removal is desirable. We present a tactile resonance sensor made of PZT ceramics, mounted in a 3D motorized translation stage for scanning and measuring tissue stiffness for detecting cancer in human prostate. The sensor may be used during surgery for guidance, scanning the prostate surface for the presence of cancer, indicating migration of cancer cells into surrounding tissue. Ten fresh prostates, obtained from patients undergoing prostate cancer surgery, were cut into 0.5 cm thick slices. Each slice was measured for tissue stiffness at about 25 different sites and compared to histology for validation cancer prediction by stiffness. The statistical analysis was based on a total of 148 sites with non-cancer and 40 sites with cancer. Using a generalized linear mixed model (GLMM), the stiffness data predicted cancer with an area under the curve of 0.74, after correcting for overfitting using bootstrap validation. Mean prostate stiffness on the logarithmic scale (p = 0.015) and standardized Z-scores (p = 0.025) were both significant predictors of cancer. This study concludes that stiffness measured by the tactile resonance sensor is a significant predictor of prostate cancer with potential for future development towards a clinical instrument for surgical guidance.

Dyspnea is common after a pulmonary embolism. Often, but not always, the dyspnea can be explained by pre-existing comorbidities, and only rarely by chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is probably the extreme manifestation of a far more common condition, called the post-pulmonary embolism syndrome. The purpose of this retrospective study was to investigate the prevalence and predictors of dyspnea among Swedish patients that survived a pulmonary embolism, compared to the general population. All Swedish patients diagnosed with an acute pulmonary embolism in 2005 (n = 5793) were identified via the Swedish National Patient Registry. Patients that lived until 2007 (n = 3510) were invited to participate. Of these, 2105 patients responded to a questionnaire about dyspnea and comorbidities. Data from the general population (n = 1905) were acquired from the multinational MONItoring of trends and determinants in CArdiovascular disease health survey, conducted in 2004. Patients with pulmonary embolism had substantially higher prevalences of both exertional dyspnea (53.0% vs. 17.3%, odds ratio (OR): 5.40, 95% confidence intervals (CI): 4.61–6.32) and wake-up dyspnea (12.0% vs. 1.7%, OR: 7.7, 95% CI: 5.28–11.23) compared to control subjects. These differences remained after adjustments and were most pronounced among younger patients. The increased risk for exertional dyspnea and wake-up dyspnea remained after propensity score matching (OR (95% CI): 4.11 (3.14–5.38) and 3.44 (1.95–6.06), respectively). This population-based, nation-wide study demonstrated that self-reported dyspnea was common among patients with previous pulmonary embolism. This finding suggested that a post-pulmonary embolism syndrome might be present, which merits further investigation.

IntroductionExercise interventions have a strong evidence base for falls prevention. However, exercise can be challenging to implement and often has limited reach and poor adherence. Digital technology provides opportunities for both increased access to the intervention and support over time. Further knowledge needs to be gained regarding the effectiveness of completely self-managed digital exercise interventions. The main objective of this study is to compare the effectiveness of a self-managed digital exercise programme, Safe Step, in combination with monthly educational videos with educational videos alone, on falls over 1 year in older community-dwelling adults.Methods and analysisA two-arm parallel randomised controlled trial will be conducted with at least 1400 community-living older adults (70+ years) who experience impaired balance. Participants will be recruited throughout Sweden with enrolment through the project website. They will be randomly allocated to either the Safe Step exercise programme with additional monthly educational videos about healthy ageing and fall prevention, or the monthly education videos alone. Participants receiving the exercise intervention will be asked to exercise at home for at least 30 min, 3 times/week with support of the Safe Step application. The primary outcome will be rate of falls (fall per person year). Participants will keep a fall calendar and report falls at the end of each month through a digital questionnaire. Further assessments of secondary outcomes will be made through self-reported questionnaires and a self-test of 30 s chair stand test at baseline and 3, 6, 9 and 12 months after study start. Data will be analysed according to the intention-to-treat principle.Ethics and disseminationEthical approval was obtained by The Regional Ethical Review Board in Umeå (Dnr 2018/433-31). Findings will be disseminated through the project web-site, peer-reviewed journals, national and international conferences and through senior citizen organisations’ newsletters.Trial registration numberNCT03963570.

Background Serial 3D models can be used to analyze changes, but correct superimposition is crucial before measurements can be assessed. Earlier studies show that every palatal structure changes due to growth or treatment. Here, we describe a new method that uses an algorithm-based analysis to perform superimpositions and measurements in maxillary 3D models. This method can be used to identify deformations. In a second step, only unchanged areas are used for superimposition. Objectives This study investigates the validity and reliability of this novel method. Methods Digital 3D models from 16 cases were modified by an independent 3D engineer to simulate space closure and growth. True values for tooth movements were available as reference. Measurements and repeated measurements were performed by four observers. Results The total tooth movement had an absolute mean error of 0.0225 mm (SD 0.03). The intraclass correlation coefficient (ICC) was 0.9996. Rotational measurements had an absolute mean error of 0.0291 degrees (SD 0.04 degrees) and an ICC of 0.9999. Limitations Serial models need to be taken with a moderate interval (1 to 2 years). Obvious changed areas in the palate need to be cropped before processing the models. Conclusion The tested method is valid and reliable with excellent accuracy and precision even when changes through growth or orthodontic treatment occur.

Background: Observational studies have linked low vitamin D status to unfavorable cardiometabolic risk markers, but double-blinded vitamin D intervention studies in children are scarce. Objectives: The aim was to evaluate the effect of different doses of a vitamin D supplement on cardiometabolic risk markers in young healthy Swedish children with fair and dark skin. Methods: Cardiometabolic risk markers were analyzed as secondary outcomes of a double-blind, randomized, milk-based vitamin D intervention trial conducted during late fall and winter in 2 areas of Sweden (latitude 63°N and 55°N, respectively) in both fair- and dark-skinned 5- to 7-y-old children. During the 3-mo intervention, 206 children were randomly assigned to a daily milk-based vitamin D3 supplement of either 10 or 25 µg or placebo (2 µg; only at 55°N). Anthropometric measures, blood pressure, serum 25-hydroxyvitamin D [25(OH)D], total cholesterol, HDL cholesterol, apoA-I, apoB, and C-reactive protein (CRP) were analyzed and non–HDL cholesterol calculated at baseline and after the intervention. Results: At baseline, serum 25(OH)D was negatively associated with systolic and diastolic blood pressure (β = −0.194; 95% CI: −0.153, −0.013; and β = −0.187; 95% CI: −0.150, −0.011, respectively). At follow-up, there was no statistically significant difference in any of the cardiometabolic markers between groups. Conclusions: We could not confirm any effect of vitamin D supplementation on serum lipids, blood pressure, or CRP in healthy 5- to 7-y-old children. The study was registered at clinicaltrials.gov (NCT01741324).

BACKGROUND/AIM Globally, an increasing proportion of cancer patients are aged >65 years and many are aged >70 years. Treatment of the elderly with lung cancer has, therefore, become an important issue. We performed a retrospective study of our patients to demonstrate how octogenarians with non-small cell lung cancer (NSCLC) are treated in real-life clinical practice. PATIENTS AND METHODS This was a retrospective observational study of all elderly (≥80 years) patients with NSCLC referred to the Department of Respiratory Medicine and Allergy, Karolinska Hospital, Sweden, 2003-2010, and followed until June, 2016. RESULTS In total, 452 patients, 216 (47.8%) men and 236 (52.2%) women, were included. The mean and median age was 83 years; 28 (6.2%) were aged 90 years or more. Current or former smokers constituted 91.1%, with men having smoked more (p

Selecting a suitable body posture measurement method requires performance indices of candidate tools. Such data are lacking for observational assessments made at a high degree of resolution. The aim of this study was to determine the performance (bias and between- and within-observer variance) of novice observers estimating upper arm elevation postures assisted by posture matching software to the nearest degree from still images taken under ideal conditions. Estimates were minimally biased from true angles: the mean error across observers was less than 2°. Variance between observers was minimal. Considerable variance within observers, however, underlined the risk of relying on single observations. Observers were more proficient at estimating 0° and 90° postures, and less proficient at 60°. Thus, under ideal visual conditions observers, on average, proved proficient at high resolution posture estimates; further investigation is required to determine how non-optimal image conditions, as would be expected from occupational data, impact proficiency.

Implantable defibrillators (ICDs) successfully terminate ventricular arrhythmias in hypertrophic cardiomyopathy (HCM), protect against bradycardia, and monitor atrial arrhythmias. This may alter the natural history and causes of death.This nationwide observational longitudinal retrospective study of all HCM patients implanted during 1995-2012 obtained data from the Swedish ICD Registry, the National Patient Register, the Cause of Death Register, and were validated by review of medical records.Of 342 patients (mean age 51.8 years, 70.8% males), 45 died during a total follow-up of 1847 years (mean 5.4 years). Mean age at death was 68.2 years (range 21-83 years; 12 were ≥75 years). Mean follow-up time among the deceased was 4.9 years (quartiles 1.4-7.4 years). All-cause mortality was higher in HCM patients compared with the age and sex-matched Swedish general population (standardized mortality ratio 3.4; 95% confidence interval 2.4-4.5; P 0.001). Main cause of death was heart failure (n = 27), stroke (n = 5), cancer (n = 3), myocardial infarction (n = 2), sepsis (n = 2), and others (n = 4). Two patients died suddenly, one after the ICD was turned off because of inappropriate shocks, and one patient whose device system was removed after infection. HCM was the main cause of death in 76% of the cases, mainly because of progressive heart failure.For HCM patients, ICDs almost eliminate premature arrhythmic death and result in a shift to heart failure as the cause of death in the majority of cases. Still, mortality in HCM patients remains elevated and management of heart failure and comorbidities must be improved to increase survival.

Background Risk stratification of sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is mainly based on evaluations from patients at highly specialized centers.Aim To evaluate risk mar ...

Purpose: To study the impact of corneal guttata on postoperative visual acuity and patients' self-assessed visual function after cataract surgery. Setting: Patient data from 49 Swedish cataract surgery units. Design: Retrospective cross-sectional register-based study. Methods: Data from patients who had cataract surgery from 2010 to 2017 and completed the Catquest-9SF questionnaire were obtained from the Swedish National Cataract Register. Logistic proportional odds regression was used to model the impact of corneal guttata on the visual acuity and self-assessed visual function. Adjustments were made for age, sex, ocular comorbidities, days to follow-up, preoperative corrected distance visual acuity (CDVA) and preoperative Rasch person score. The main outcome measures were postoperative CDVA and Rasch person score calculated from the Catquest-9SF questionnaire. Results: The study comprised data from 33 741 patients. Cataract surgery greatly improved CDVA and self-assessed visual function in patients both with and without corneal guttata. Still, corneal guttata was significantly associated with a poorer visual acuity and a worse self-assessed visual function after cataract surgery. The negative effect of corneal guttata on visual acuity was most prominent during the first 3 weeks postoperatively, but it persisted at least 3 months postoperatively. Conclusions: Patients with corneal guttata benefit substantially from cataract surgery but have an additional risk for inferior results compared with patients without corneal guttata. These findings could serve as valuable tools in clinical practice, in particular, when deciding to perform cataract surgery and how to inform the patient about surgical benefits and risks. Reply: Viberg, Andreas MD; Liv, Per PhD; Behndig, Anders MD, PhD; Lundström, Mats MD, PhD; Byström, Berit MD, PhD Impact of corneal guttata on cataract surgery results, Journal of Cataract & Refractive Surgery: November 2019 - Volume 45 - Issue 11 - p 1692-1693 doi: 10.1016/j.jcrs.2019.08.049

Inappropriate ICD Shocks and Complications in HCM IntroductionThe expanded use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac death (SCD) in hypertrophic cardiomyopathy ...

Previous research suggests inclinometers (INC) underestimate upper arm elevation. This study was designed to quantify possible bias in occupationally relevant postures, and test whether INC perform ...

Chemoradiotherapy is the standard of care for inoperable stage III non-small cell lung cancer (NSCLC). This treatment, however, offers only a small chance of cure and is associated with many side effects. Little research has been made concerning which patients benefit most/least from the treatment. The present study evaluates the prognostic value of anemia, leukocytosis and thrombocytosis at diagnosis in this treatment setting. In the present study, data were collected retrospectively for 222 patients from two different phase II studies conducted between 2002-2007 in Sweden with patients treated with chemoradiotherapy for stage IIIA-IIIB NSCLC. Clinical data and the serum values of hemoglobin (Hgb), White blood cells (WBC) and Platelets (Plt) at enrollment were collected for all patients and studied in relation to overall survival using Kaplan-Meier product-limit estimates and a multivariate Cox proportional hazards regression model. The results showed that patients with thrombocytosis (Plt > 350 x 109/L) had a shorter median overall survival (14.5 months) than patients with normal Plt at baseline (23.7 months). Patients with leukocytosis (WBC > 9 x 109/L) had a shorter median survival (14.9 months) than patients with a normal WBC at baseline (22.5 months). However, in a multivariate model including all lab parameters and clinical factors, only thrombocytosis and performance status displayed a prognostic significance. In Conclusion, thrombocytosis showed to be an independent prognostic marker associated with shorter overall survival in stage III NSCLC treated with curatively intended chemoradiotherapy. This knowledge can potentially be used together with established prognostic factors, such as performance status when choosing the optimal therapy for the individual patient in this clinical setting.

Background: A pacemaker system consists of one or two leads connected to a device that is implanted into a pocket formed just below the collarbone. This pocket is typically subcutaneous, that is, located just above the pectoral fascia. Even though the size of pacemakers has decreased markedly, complications due to superficial implants do occur. An alternative technique would be intramuscular placement of the pacemaker device, but there are no randomized controlled trials (RCTs) to support this approach, which is the rationale for the Placement Of Cardiac PacemaKEr Trial (POCKET). The aim is to study if intramuscular is superior to subcutaneous placement of a pacemaker pocket. Methods: In October 2016, we started to enroll 200 consecutive patients with an indication for bradycardia pacemaker implantation. Patients are randomized to random block sizes, stratified by age group (cut-off: 65 years) and sex, and then randomized to either subcutaneous or intramuscular implant. A concealed allocation procedure is employed, using sequentially numbered, sealed envelopes. Pocket site is blinded to the patient and in all subsequent care. The primary endpoint is patient overall satisfaction with the pocket location at 24 months as measured using a visual analog scale (VAS) 0-10. Secondary endpoints are: complications, patient-reported satisfaction at 1, 12, and 24 months (overall satisfaction, pain, discomfort, degree of unsightly appearance, movement problems, and sleep problems due to device). Conclusions: POCKET is a prospective interventional RCT designed to evaluate if intramuscular is superior to subcutaneous placement of a bradycardia pacemaker during a two-year follow-up.

Assessment of working postures by observation is a common practice in ergonomics. The present study investigated whether monetary resources invested in a video-based posture observation study should preferably be spent in collecting many video recordings of the work and have them observed once by one observer, or in having multiple observers rate postures repeatedly from fewer videos. The study addressed this question from a practitioner's perspective by focusing two plausible scenarios: documenting the mean exposure of one individual, and of a specific occupational group. Using a data set of observed working postures among hairdressers, empirical values of posture variability, observer variability, and costs for recording and observing one video were entered into equations expressing the total cost of data collection and the information (defined as 1/SD) provided by the resulting estimates of two variables: percentage time with the arm elevated15° and90°. Sixteen measurement strategies involving 1-4 observers repeating their posture ratings 1-4 times were examined for budgets up to €2000. For both posture variables and in both the individual and group scenario, the most cost-efficient strategy at any specific budget was to engage 3-4 observers and/or having observer(s) rate postures multiple times each. Between 17% and 34% less information was produced when using the commonly practiced approach of having one observer rate a number of video recordings one time each. We therefore recommend observational posture assessment to be based on video recordings of work, since this allows for multiple observations; and to allocate monetary resources to repeated observations rather than many video recordings.

Risk stratification of sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is mainly based on evaluations from patients at highly specialized centers.To evaluate risk markers for appropriate implantable cardioverter defibrillator (ICD) therapy in an unselected, nationwide cohort of HCM.Patients with an ICD due to HCM were identified from the Swedish ICD Registry since its start in 1995, merged with Patient Register data, and medical records were retrieved. Risk markers for ventricular arrhythmias leading to appropriate ICD therapy were analyzed using Cox proportional hazard ratio (HR).Of 321 patients (70.1% males), at least one appropriate therapy occurred in 77 (24.0%) during a mean follow-up of 5.4 years (5.3% per year; primary prevention 4.5%, secondary prevention 7.0%). Cumulative incidences at 1 year, 3 years, and 5 years were 8.1%, 15.3%, and 21.3%, respectively. Cardioversion effectively restored rhythm in 52% of the first episode and antitachycardia pacing was sufficient in the remaining. For the whole cohort, ejection fraction (EF)50% (HR 2.63; P0.001) was associated with appropriate ICD therapy. In primary prevention, patients with established risk markers experienced appropriate therapy; atrial fibrillation (AF; HR 2.54; P = 0.010), EF50% (HR 2.78; P = 0.004), and nonsustained ventricular tachycardia (HR 1.80; P = 0.109) had the highest HR, and wall thickness ≥ 30 mm, syncope, exercise blood pressure response, or family history of SCD had weaker associations.ICD therapy successfully terminates ventricular arrhythmias in HCM. In addition to conventional risk markers, a history of AF or EF50% may be considered in risk stratification.

The expanded use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) based on risk stratification in individuals without known previous ventricular arrhythmia is justified by an acceptable risk of device-related adverse events. Such complications, leading to surgical procedures or inappropriate electrical shocks, may impact mortality, morbidity, quality of life, and cost-effectiveness.From the Swedish ICD Registry, implants due to HCM since 1995 until November 2012 in patients aged ≥18 years were identified and medical records reviewed. Inappropriate ICD shock occurred in 14.3% (46 of 321 patients; mean follow-up 5.4 years) with a recurrent episode in 28.2% of them. In multivariable analysis, hazard ratio (HR) for atrial fibrillation was 3.5 (95% confidence interval 1.8-6.8; P0.001) but showed no significant association to male sex (HR = 0.77), age (HR = 0.99), secondary indication (HR = 1.02) or device, ICD-DR/CRTD vs. ICD-VR (HR 1.07). Inappropriate shocks were triggered by atrial fibrillation/flutter or ectopic tachycardia (56.5%), sinus tachycardia (14.5%), lead dysfunction (14.5%), and T-wave oversensing (13.0%). A reintervention, besides elective device replacement, occurred in 92 patients (totally 150 procedures). The majority were lead-related (70.0%) procedures, especially of the ICD lead. Reintervention was associated with female sex (HR = 1.6 P = 0.04).Inappropriate ICD shock triggered by atrial arrhythmias, lead dysfunction, or complications requiring surgical interventions, is a concern in HCM patients who will be eligible for long-term prevention of sudden death. Efforts to avoid adverse events and provide balanced risk-benefit information are important, especially in primary prevention.

Digging deeper into the assessment of upper arm elevation angles using standard inclinometry

An increasing proportion of cancer patients are aged >65 years and many are aged >70 years. Treatment of the elderly with lung cancer has, therefore, become an important issue; so we performed a retrospective study of our patients to demonstrate how elderly patients with NSCLC are treated in real-life, clinical practice. All patients aged ≥70 years with NSCLC at our department were reviewed retrospectively. In total, 1059 patients (50.8% of all NSCLC patients). Of these patients, 243 (22.9%) received chemotherapy, 164 (70.4%) of whom were treated with a platinum doublet using carboplatin. Second- and third-line chemotherapy were given to 31.4% and 13.9% of patients, respectively. Median overall survival was 289 and 320 days for male and female patients, respectively. Patients with performance status (PS) 0 experienced significantly better survival than patients with PS1 or PS 2: 410, 314, and 204 days, respectively. Age was of less importance, with patients aged 70–79 years versus those aged ≥80 years. Treatment of elderly NSCLC patients with chemotherapy is feasible if they have a good PS and appears to prolong survival. In this study, we found no significant differences in survival either between age groups or genders.

Many video-based techniques for assessing postures at work have been developed. Choosing the most appropriate technique should be based on an evaluation of different alternatives in terms of their ability to produce posture information at low input costs, i.e. their cost efficiency. This study compared four video-based techniques for assessing upper arm postures, using cost and error data from an investigation on hairdressers. Labour costs associated with the posture assessments from the video recordings were the dominant factor in the cost efficiency comparison. Thus, a work sampling technique associated with relatively large errors appeared, in general, to be the most cost-efficient because it was labour-saving. Measurement bias and other costs than labour cost for posture assessment influenced the ranking and economic evaluation of techniques, as did the applied measurement strategy, i.e. the numbers of video recordings and repeated assessments of them.The cost efficiency of four video-based techniques for assessing upper arm postures was compared. Work sampling techniques were in general more cost efficient than continuous observations since they were labour-saving. Whilst a labour cost dominated the comparison, 'hidden costs', bias and measurement strategy also influenced this dominance.

In ergonomics, assessing the working postures of an individual by observation is a very common practice. The present study investigated whether monetary resources devoted to an observational study should preferably be invested in collecting many video recordings of the work, or in having several observers estimate postures from available videos multiple times. On the basis of a data set of observed working postures among hairdressers, necessary information in terms of posture variability, observer variability, and costs for recording and observing videos was entered into equations providing the total cost of data collection and the precision (informative value) of the resulting estimates of two variables: percentages time with the arm elevated15 degrees and90 degrees. In all 160 data collection strategies, differing with respect to the number of video recordings and the number of repeated observations of each recording, were simulated and compared for cost and precision. For both posture variables, the most cost-efficient strategy for a given budget was to engage 4 observers to look at available video recordings, rather than to have one observer look at more recordings. Since the latter strategy is the more common in ergonomics practice, we recommend reconsidering standard practice in observational posture assessment.

OBJECTIVES: To investigate the statistical efficiency of strategies for sampling upper arm elevation data, which differed with respect to sample sizes and sample allocations within and across measurement days. The study was also designed to compare standard theoretical predictions of sampling efficiency, which rely on several assumptions about the data structure, with 'true' efficiency as determined by bootstrap simulations.METHODS: Sixty-five sampling strategies were investigated using a data set containing minute-by-minute values of average right upper arm elevation, percentage of time with an arm elevated 90° in a population of 23 house painters, 23 car mechanics, and 26 machinists, all followed for four full working days. Total sample times per subject between 30 and 240 min were subdivided into continuous time blocks between 1 and 240 min long, allocated to 1 or 4 days per subject. Within day(s), blocks were distributed using either a random or a fixed-interval principle. Sampling efficiency was expressed in terms of the variance of estimated mean exposure values of 20 subjects and assessed using standard theoretical models assuming independence between variables and homoscedasticity. Theoretical performance was compared to empirical efficiencies obtained by a nonparametric bootstrapping procedure.RESULTS: We found the assumptions of independence and homoscedasticity in the theoretical model to be violated, most notably expressed through an autocorrelation between measurement units within working days. The empirical variance of the mean exposure estimates decreased, i.e. sampling efficiency increased, for sampling strategies where measurements were distributed widely across time. Thus, the most efficient allocation strategy was to organize a sample into 1-min block collected at fixed time intervals across 4 days. Theoretical estimates of efficiency generally agreed with empirical variances if the sample was allocated into small blocks, while for larger block sizes, the empirical 'true' variance was considerably larger than predicted by theory. Theory overestimated efficiency in particular for strategies with short total sample times per subject.CONCLUSIONS: This study demonstrates that when exposure data are autocorrelated within days-which we argue is the major reason why theory overestimates sampling performance-sampling efficiency can be improved by distributing the sample widely across the day or across days, preferably using a fixed-interval strategy. While this guidance is particularly valid when small proportions of working days are assessed, we generally recommend collecting more data than suggested by theory if a certain precision of the resulting exposure estimate is needed. More data per se give a better precision and sampling larger proportion(s) of the working day(s) also alleviate the negative effects of possible autocorrelation in data.

To describe upper arm postures and movements among female hairdressers, including the variability between hairdressers, between days within hairdresser, and between tasks, as a basis for understanding the characteristics of exposures in the job, considering possible sources of variation and recovery, and discussing appropriate exposure assessment strategies.Data on upper arm postures were collected using inclinometers during four working days the same week from 28 female hairdressers working in 13 salons. Twenty of the hairdressers noted customer on and off times in a diary, to allow separate analyses of customer tasks (CT) and auxiliary non-customer tasks (AT), including breaks. For a number of posture and movement variables, mean values and variance components between subjects (BS) and within subjects between days (BD) were estimated using restricted maximum likelihood algorithms in one-way random effect models.For the 20 hairdressers with diaries, CT accounted for 279 min (58%) (SD(BS) = 39 min and SD(BD) = 85 min) of the working day and AT and breaks for 207 min (42%) (SD(BS) = 46 min and SD(BD) = 88 min). The hairdressers worked with the right arm elevated60 degrees for 6.8% of the whole job (SD(BS) = 2.8% and SD(BD) = 2.0%). On average, the hairdressers worked with the right arm elevated60 degrees for 9.0% of the time during CT, compared to 3.7% during AT, resulting in a contrast between tasks of 0.35.Hairdressers may be at risk for developing musculoskeletal disorders in the neck and shoulders due to a considerable occurrence of highly elevated arms, especially during CT. On the other hand, we do not find reasons to classify hairdressing as a job with too little variation. Posture variability between days within hairdressers was in the same order of magnitude as that between hairdressers, suggesting that 'typical' workdays do not exist. The exposure contrast between CT and AT for variables describing elevated arm postures indicates that for these variables a simple task-based approach for estimating job exposure could be successful.

Background Information on exposure variability, expressed as exposure variance components, is of vital use in occupational epidemiology, including informed risk control and efficient study design. While accurate and precise estimates of the variance components are desirable in such cases, very little research has been devoted to understanding the performance of data sampling strategies designed specifically to determine the size and structure of exposure variability. The aim of this study was to investigate the accuracy and precision of estimators of between-subjects, between-days and within-day variance components obtained by sampling strategies differing with respect to number of subjects, total sampling time per subject, number of days per subject and the size of individual sampling periods. Methods Minute-by-minute values of average elevation, percentage time above 90° and percentage time below 15° were calculated in a data set consisting of measurements of right upper arm elevation during four full shifts from each of 23 car mechanics. Based on this parent data, bootstrapping was used to simulate sampling with 80 different combinations of the number of subjects (10, 20), total sampling time per subject (60, 120, 240, 480 minutes), number of days per subject (2, 4), and size of sampling periods (blocks) within days (1, 15, 60, 240 minutes). Accuracy (absence of bias) and precision (prediction intervals) of the variance component estimators were assessed for each simulated sampling strategy. Results Sampling in small blocks within days resulted in essentially unbiased variance components. For a specific total sampling time per subject, and in particular if this time was small, increasing the block size resulted in an increasing bias, primarily of the between-days and the within-days variance components. Prediction intervals were in general wide, and even more so at larger block sizes. Distributing sampling time across more days gave in general more precise variance component estimates, but also reduced accuracy in some cases. Conclusions Variance components estimated from small samples of exposure data within working days may be both inaccurate and imprecise, in particular if sampling is laid out in large consecutive time blocks. In order to estimate variance components with a satisfying accuracy and precision, for instance for arriving at trustworthy power calculations in a planned intervention study, larger samples of data will be required than for estimating an exposure mean value with a corresponding certainty.