Recent Submissions

  • Ábendingar og árangur ósæðarlokuísetningar með þræðingartækni (TAVI) á Íslandi

    Katrín Júníana Lárusdóttir; Hjalti Guðmundsson; Árni Johnsen; Martin Ingi Sigurðsson; Tómas Guðbjartsson; Ingibjörg Jóna Guðmundsdóttir; 1 Læknadeild Háskóla Íslands, 2 hjartalækningadeild, 3 hjarta- og lungnaskurðdeild, 4 svæfinga- og gjörgæsludeild Landspítala (Læknafélag Íslands, 2021-03)
    INNGANGUR Ósæðarlokuþrengsl eru algengasti lokusjúkdómurinn á Vesturlöndum. Hefðbundin meðferð við alvarlegum þrengslum hefur verið opin ósæðarlokuskipti en síðastliðin ár hefur ósæðarlokuísetning með þræðingartækni (TAVI) rutt sér til rúms hér á landi sem erlendis. Markmið rannsóknarinnar var að kanna árangur TAVI-aðgerða á Íslandi með áherslu á ábendingar, fylgikvilla og lifun. EFNIVIÐUR OG AÐFERÐIR Rannsóknin var afturskyggn og tók til allra TAVI-aðgerða sem framkvæmdar hafa verið á Íslandi frá janúar 2012 til loka júní 2020. Skráðir voru bakgrunnsþættir sjúklinga, afdrif og fylgikvillar en einnig heildarlifun sem borin var saman við íslenskt viðmiðunarþýði af sama kyni og aldri. Meðal eftirfylgd var 2,4 ár. NIÐURSTÖÐUR Alls voru framkvæmdar 189 aðgerðir (meðalaldur 83 ± 6 ár, 41,8% konur), allar með sjálfþenjandi lífrænni gerviloku. Flestir sjúklingar (81,5%) höfðu alvarleg hjartabilunareinkenni (NYHA-flokkar III-IV) og miðgildi EuroSCORE-II var 4,9 (bil 0,9-32). Á hjartaómskoðun fyrir aðgerð var hámarks þrýstingsfallandi að meðaltali 78 mmHg og lokuflatarmál 0,67 cm2 . Rúmlega fjórðungur (26,5%) sjúklinga þurfti ísetningu varanlegs gangráðs í kjölfar TAVI-aðgerðar. Aðrir fylgikvillar voru oftast æðatengdir (13,8%), en hjartaþröng greindist í 3,2% tilfella og heilablóðfall í 2,6%. . Mikill randstæður leki við gerviloku sást hjá 0,5% sjúklinga. Dánartíðni innan 30 daga frá aðgerð var 1,6% (n=3) og lifun einu ári frá aðgerðadegi 93,5% (95% ÖB: 89.8-97.3). Heildarlifun var sambærileg lifun viðmiðunarþýðis af sama kyni og sama aldri (p=0,23). ÁLYKTANIR Árangur TAVI-aðgerða hér á landi er mjög góður, ekki síst þegar litið er til lágrar 30 daga dánartíðni og heildarlifunar sem var sambærileg og hjá viðmiðunarþýði. Auk þess var tíðni alvarlegra fylgikvilla lág.
  • Automatic fundus image quality assessment on a continuous scale.

    Karlsson, Robert A; Jonsson, Benedikt A; Hardarson, Sveinn H; Olafsdottir, Olof B; Halldorsson, Gisli H; Stefansson, Einar; 1Faculty of Medicine at the University of Iceland, Sæmundargata 2, 102, Reykjavík, Iceland; Faculty of Electrical and Computer Engineering at the University of Iceland, Sæmundargata 2, 102, Reykjavík, Iceland. Electronic address: rak32@hi.is. 2Faculty of Electrical and Computer Engineering at the University of Iceland, Sæmundargata 2, 102, Reykjavík, Iceland. 3Faculty of Medicine at the University of Iceland, Sæmundargata 2, 102, Reykjavík, Iceland. 4Faculty of Medicine at the University of Iceland, Sæmundargata 2, 102, Reykjavík, Iceland; Landspitali - the National University Hospital of Iceland, Hringbraut 10, 101, Reykjavík, Iceland. 5Oxymap ehf, Vatnsmýrarvegur 16, 101, Reykjavík, Iceland. (Elsevier, 2020-11-12)
    Fundus photography is commonly used for screening, diagnosis, and monitoring of various diseases affecting the eye. In addition, it has shown promise in the diagnosis of brain diseases and evaluation of cardiovascular risk factors. Good image quality is important if diagnosis is to be accurate and timely. Here, we propose a method that automatically grades image quality on a continuous scale which is more flexible than binary quality classification. The method utilizes random forest regression models trained on image features discovered automatically by combining basic image filters using simulated annealing as well as features extracted with the discrete Fourier transform. The method was developed and tested on images from two different fundus camera models. The quality of those images was rated on a continuous scale from 0.0 to 1.0 by five experts. In addition, the method was tested on DRIMDB, a publicly available dataset with binary quality ratings. On the DRIMDB dataset the method achieves an accuracy of 0.981, sensitivity of 0.993 and specificity of 0.958 which is consistent with the state of the art. When evaluating image quality on a continuous scale the method outperforms human raters. Keywords: Fundus image quality assessment; Fundus imaging; Machine learning; Simulated annealing.
  • PopDel identifies medium-size deletions simultaneously in tens of thousands of genomes.

    Niehus, Sebastian; Jónsson, Hákon; Schönberger, Janina; Björnsson, Eythór; Beyter, Doruk; Eggertsson, Hannes P; Sulem, Patrick; Stefánsson, Kári; Halldórsson, Bjarni V; Kehr, Birte; et al. (Nature Publishing Group, 2021-02-01)
    Thousands of genomic structural variants (SVs) segregate in the human population and can impact phenotypic traits and diseases. Their identification in whole-genome sequence data of large cohorts is a major computational challenge. Most current approaches identify SVs in single genomes and afterwards merge the identified variants into a joint call set across many genomes. We describe the approach PopDel, which directly identifies deletions of about 500 to at least 10,000 bp in length in data of many genomes jointly, eliminating the need for subsequent variant merging. PopDel scales to tens of thousands of genomes as we demonstrate in evaluations on up to 49,962 genomes. We show that PopDel reliably reports common, rare and de novo deletions. On genomes with available high-confidence reference call sets PopDel shows excellent recall and precision. Genotype inheritance patterns in up to 6794 trios indicate that genotypes predicted by PopDel are more reliable than those of previous SV callers. Furthermore, PopDel's running time is competitive with the fastest tested previous tools. The demonstrated scalability and accuracy of PopDel enables routine scans for deletions in large-scale sequencing studies.
  • Cumulative Occupational Exposures and Lung-Function Decline in Two Large General-Population Cohorts.

    Lytras, Theodore; Beckmeyer-Borowko, Anna; Kogevinas, Manolis; Kromhout, Hans; Carsin, Anne-Elie; Antó, Josep Maria; Bentouhami, Hayat; Weyler, Joost; Heinrich, Joachim; Nowak, Dennis; et al. (American Thoracic Society, 2021-02)
    Rationale: Few longitudinal studies have assessed the relationship between occupational exposures and lung-function decline in the general population with a sufficiently long follow-up.Objectives: To examine the potential association in two large cohorts: the ECRHS (European Community Respiratory Health Survey) and the SAPALDIA (Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults).Methods: General-population samples of individuals aged 18 to 62 were randomly selected in 1991-1993 and followed up approximately 10 and 20 years later. Spirometry (without bronchodilation) was performed at each visit. Coded complete job histories during follow-up visits were linked to a job-exposure matrix, generating cumulative exposure estimates for 12 occupational exposures. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were jointly modeled in linear mixed-effects models, fitted in a Bayesian framework, taking into account age and smoking.Results: A total of 40,024 lung-function measurements from 17,833 study participants were analyzed. We found accelerated declines in FEV1 and the FEV1/FVC ratio for exposure to biological dust, mineral dust, and metals (FEV1 = -15.1 ml, -14.4 ml, and -18.7 ml, respectively; and FEV1/FVC ratio = -0.52%, -0.43%, and -0.36%, respectively; per 25 intensity-years of exposure). These declines were comparable in magnitude with those associated with long-term smoking. No effect modification by sex or smoking status was identified. Findings were similar between the ECRHS and the SAPALDIA cohorts.Conclusions: Our results greatly strengthen the evidence base implicating occupation, independent of smoking, as a risk factor for lung-function decline. This highlights the need to prevent or control these exposures in the workplace.
  • Hematopoietic Stem Cell Transplantation Resolves the Immune Deficit Associated with STAT3-Dominant-Negative Hyper-IgE Syndrome.

    Harrison, Stephanie C; Tsilifis, Christo; Slatter, Mary A; Nademi, Zohreh; Worth, Austen; Veys, Paul; Ponsford, Mark J; Jolles, Stephen; Al-Herz, Waleed; Flood, Terence; et al. (Springer, 2021-02-01)
    Autosomal dominant hyper-IgE syndrome caused by dominant-negative loss-of-function mutations in signal transducer and activator of transcription factor 3 (STAT3) (STAT3-HIES) is a rare primary immunodeficiency with multisystem pathology. The quality of life in patients with STAT3-HIES is determined by not only the progressive, life-limiting pulmonary disease, but also significant skin disease including recurrent infections and abscesses requiring surgery. Our early report indicated that hematopoietic stem cell transplantation might not be effective in patients with STAT3-HIES, although a few subsequent reports have reported successful outcomes. We update on progress of our patient now with over 18 years of follow-up and report on an additional seven cases, all of whom have survived despite demonstrating significant disease-related pathology prior to transplant. We conclude that effective cure of the immunological aspects of the disease and stabilization of even severe lung involvement may be achieved by allogeneic hematopoietic stem cell transplantation. Recurrent skin infections and abscesses may be abolished. Donor TH17 cells may produce comparable levels of IL17A to healthy controls. The future challenge will be to determine which patients should best be offered this treatment and at what point in their disease history.
  • Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study.

    Zeitlin, J; Durox, M; Macfarlane, A; Alexander, S; Heller, G; Loghi, M; Nijhuis, J; Sól Ólafsdóttir, H; Mierzejewska, E; Gissler, M; et al. (Wiley-Blackwell, 2020-12-18)
    Objective: Robson's Ten Group Classification System (TGCS) creates clinically relevant sub-groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates. Design: Observational study using routine data. Setting: Twenty-seven EU member states plus Iceland, Norway, Switzerland and the UK. Population: All births at ≥22 weeks of gestational age in 2015. Methods: National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups. Main outcome measures: Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups. Results: Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions. Conclusions: Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence-based caesarean policies. Tweetable abstract: Many European countries can provide Robson's Ten-Group Classification to improve caesarean rate comparisons. Keywords: Caesarean birth; Europe; Robson classification; Ten-Group Classification System; health information systems; perinatal health indicators.
  • Arrest-related death on the basis of a drug-induced excited delirium syndrome.

    Kunz, S N; Þórðardóttir, S; Jónasson, J G; 1Institute of Forensic Medicine, Ulm University Hospital, Germany; Ulm University, Germany. Electronic address: sebastian.kunz@uniklinik-ulm.de. 2Department of Pharmacology and Toxicology, University of Iceland, Reykjavik, Iceland. 3Department of Pathology, Landspítali University Hospital Reykjavik, Iceland. (Elsevier, 2020-11-26)
    Aims: In typical arrest-related death (ARD) scenarios, the victims often show signs of excited delirium syndrome (ExDS), intoxication, exhaustion and/or suffered from a preexisting physical or psychiatrical condition, all of which could have caused or at least triggered the person's death. Since autopsy findings are very rare in such cases, a clear clinicopathologic diagnosis and thus mechanism of death is rarely found. Methods: We present a case of a 25-year old woman, who died while being arrested by the police. Based on the patient's medical history, autopsy findings, contradicting witness testimonies, and reliable clinical and toxicological blood parameters, the most probable diagnosis is discussed. Results: The cause of death was determined as cardiac arrest subsequent to a combination of excited delirium syndrome, physical exhaustion and respiratory impairment. The manner of death was unnatural and juridically, the charges were dropped. Conclusions: In cases, where the cause and mechanism of death can only be diagnosed by exclusion, police collaboration, detailed clinical history (past and present) as well as clinical blood parameter analyses are necessary to help evaluating possible contributing factors and the most probable cause of death in ARD. Keywords: Amphetamine; Arrest-related death; Asphyxia; Excited delirium syndrome; Forensic medicine; Restraint.
  • Seaweed extract improves carbohydrate metabolism in overweight and obese adults

    Elidottir, Anita S.; Sveinsdottir, Kolbrun; Ingadottir, Bergros; Geirsdottir, Olof G.; Jonsson, Palmi V.; Rothenberg, Elisabeth; Hardardottir, Ingibjorg; Freysdottir, Jona; Ramel, Alfons; aFaculty of Food Science and Nutrition, University of Iceland, Reykjavik, Iceland bThe Icelandic Food and Biotech R&D Institute, Reykjavik, Iceland cThe Icelandic Gerontological Research Institute, Reykjavik, Iceland dDepartment of Food and Meal Science, Kristianstad University, kristianstad, Sweden eFaculty of Medicine, University of Iceland, Reykjavik, Iceland fDepartment of Immunology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (Bentham Science Publishers, 2021-01-01)
    Background: Obesity is characterized by chronic low-grade inflammation and associated with type 2 diabetes. Seaweed is one of the largest producers of biomass in the marine environment and is a rich arsenal of functional ingredients that may possess the potential to prevent type 2 diabetes. Objective: The aim was to investigate the effects of seaweed extract on glucose metabolism and markers of inflammation in overweight and obese individuals. Methods: Participants (N=76, >40 years, body mass index >25 kg/m 2 ) who volunteered for this 10week randomized, controlled, doubly blinded intervention study, were randomized into an intervention group (seaweed extract, 3 capsules=1200 mg/day) or a control group (placebo, 3 capsules/day). The extract derived from the brown seaweed bladder wrack (Fucus vesiculosus). At baseline and endpoint of the study, fasting samples were analysed for blood glucose, insulin, inflammation markers, liver enzymes and creatinine (renal function). Results: Drop out was 11.8% and not significantly different between groups. Fasting blood glucose and insulin were improved at the endpoint in the intervention group, but no changes were observed in the control group (corrected endpoint differences between groups: glucose=0.61 mmol/L, P=0.038; insulin=0.72 mu U/L, P=0.038). Measures of inflammation, liver enzymes and renal function did not change significantly during the study. Conclusion: Ingestion of seaweed extract over 10 weeks improves glucose metabolism without affecting measures of inflammation, liver function or renal function.
  • Parental occupational exposure pre- and post-conception and development of asthma in offspring.

    Pape, Kathrine; Svanes, Cecile; Sejbæk, Camilla S; Malinovschi, Andrei; Benediktsdottir, Byndis; Forsberg, Bertil; Janson, Christer; Benke, Geza; Tjalvin, Gro; Sánchez-Ramos, José Luis; et al. (Oxford University Press, 2021-01)
    Background: While direct effects of occupational exposures on an individual's respiratory health are evident, a new paradigm is emerging on the possible effects of pre-conception occupational exposure on respiratory health in offspring. We aimed to study the association between parental occupational exposure starting before conception and asthma in their offspring (at 0-15 years of age). Methods: We studied 3985 offspring participating in the Respiratory Health in Northern Europe, Spain and Australia (RHINESSA) generation study. Their mothers or fathers (n = 2931) previously participated in the European Community Respiratory Health Survey (ECRHS). Information was obtained from questionnaires on parental job history pre- and post-conception which was linked to an asthma-specific job-exposure matrix (JEM). We assessed the association between parental occupational exposure and offspring asthma, applying logistic regression models, clustered by family and adjusted for study centre, offspring sex, parental characteristics (age, asthma onset, place of upbringing, smoking) and grandparents' level of education. Results: Parental occupational exposure to microorganisms, pesticides, allergens or reactive chemicals pre-conception or both pre- and post-conception was not related to offspring asthma; in general, subgroup analyses confirmed this result. However, maternal exposure both pre- and post-conception to allergens and reactive chemicals was associated with increased odds for early-onset asthma in offspring (0-3 years of age); odds ratio 1.70 (95% CI: 1.02-2.84) and 1.65 (95% CI: 0.98-2.77), respectively. Conclusions: This study did not find evidence that parental occupational exposure, defined by an asthma JEM before conception only or during pre- and post-conception vs non-exposed, was associated with offspring asthma. Keywords: job-exposure matrices; Epidemiology; air pollutants; asthma; generation study; occupation; occupational exposure.
  • The applications of transcranial Doppler in ischemic stroke.

    Finnsdóttir, Herdis; Szegedi, István; Oláh, László; Csiba, László; 1University of Debrecen, Faculty of Medicine, Department of Surgery, Debrecen, Hungary. 2Landspítali - National University Hospital of Iceland, Department of Surgery, Reykjavík, Iceland. (Literatura Medica, 2020-11)
    Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the in-crea-sed intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Micro-em-boli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast en-chan-ced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt. Keywords: ischemic stroke; stroke; transcranial Doppler; ultrasound.
  • Analysis of graduating nursing students' moral courage in six European countries.

    Koskinen, Sanna; Pajakoski, Elina; Fuster, Pilar; Ingadottir, Brynja; Löyttyniemi, Eliisa; Numminen, Olivia; Salminen, Leena; Scott, P Anne; Stubner, Juliane; Truš, Marija; et al. (SAGE Publications, 2020-10-29)
    Background: Moral courage is defined as courage to act according to one's own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses' career. Aim: To analyse graduating nursing students' moral courage and the factors associated with it in six European countries. Research design: A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with a single question (visual analogue scale 0-100), the questionnaire also covered several background variables. Participants and research context: The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students' moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires. Ethical considerations: Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent. Results: The mean of graduating nursing students' self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0-100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students' moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves. Discussion and conclusions: In all countries, the graduating nursing students' moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research. Keywords: Ethical competence; graduating nursing student; international survey; moral courage; nursing education.
  • Fish skin grafts compared to human amnion/chorion membrane allografts: A double-blind, prospective, randomized clinical trial of acute wound healing.

    Kirsner, Robert S; Margolis, David J; Baldursson, Baldur T; Petursdottir, Kristin; Davidsson, Olafur B; Weir, Dot; Lantis, John C; 1Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. 2Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. 3Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. 4Department of Dermatology, Landspitali University Hospital of Iceland, Reykjavik, Iceland. 5Mathematics Division of the Science Institute, University of Iceland, Reykjavik, Iceland. 6Catholic Health Advanced Wound Healing Centers, Buffalo, New York. 7Division of Vascular/Endovascular Surgery, Mount Sinai St. Luke's-West Hospitals, Icahn School of Medicine, New York, New York. (2019-10-25)
    Chronic, nonhealing wounds consume a great deal of healthcare resources and are a major public health problem, associated with high morbidity and significant economic costs. Skin grafts are commonly used to facilitate wound closure. The grafts can come from the patient's own skin (autograft), a human donor (allograft), or from a different species (xenograft). A fish skin xenograft from cold-water fish (Atlantic cod, Gadus morhua) is a relatively recent option that shows promising preclinical and clinical results in wound healing. Chronic wounds vary greatly in etiology and nature, requiring large cohorts for effective comparison between therapeutic alternatives. In this study, we attempted to imitate the status of a freshly debrided chronic wound by creating acute full-thickness wounds, 4 mm in diameter, on healthy volunteers to compare two materials frequently used to treat chronic wounds: fish skin and dHACM. The purpose is to give an indication of the efficacy of the two therapeutic alternatives in the treatment of chronic wounds in a simple, standardized, randomized, controlled, double-blind study. All volunteers were given two identical punch biopsy wounds, one of which was treated with a fish skin graft and the other with dehydrated human amnion/chorion membrane allograft (dHACM). In the study, 170 wounds were treated (85 wounds per group). The primary endpoint was defined as time to heal (full epithelialization) by blinded assessment at days 14, 18, 21, 25, and 28. The superiority hypothesis was that the fish skin grafts would heal the wounds faster than the dHACM. To evaluate the superiority hypothesis, a mixed Cox proportional hazard model was used. Wounds treated with fish skin healed significantly faster (hazard ratio 2.37; 95% confidence interval: (1.75-3.22; p = 0.0014) compared with wounds treated with dHACM. The results show that acute biopsy wounds treated with fish skin grafts heal faster than wounds treated with dHACM.
  • Integration of nursing services provided to patients with heart failure living at home: A longitudinal ethnographic study.

    Bjornsdottir, Kristin; Ketilsdottir, Audur; Gudnadottir, Margret; Kristinsdottir, Inga V; Ingadottir, Brynja; 1Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavik, Iceland. 2Division of Clinical Services II (Cardiovascular Center, Landspitali - the National University Hospital of Iceland, Reykjavik, Iceland. (Wiley, 2021-01-12)
    Aims and objectives: This study aimed to (1) describe the development of integrated services between hospital-based heart failure nursing services and municipally located home care nurses' services and (2) identify the benefits of this collaboration for the development of home care nursing services. Background: Governments have called for better integration of healthcare services to respond to demographic ageing. Clinical pathways have been used to enhance integration and assure continuity between primary and secondary care. Competencies in addressing advanced health issues among home care nurses must be improved. Design: A longitudinal ethnographic study of the development of home care nursing services for persons living with heart failure. Methods: Data were field notes from observations at meetings of the steering group designing the services, visits to patients' homes and from educational sessions. Interviews were conducted with the home care nurses, heart failure nurses and focus group meetings with nurses working in home care nursing. Reporting adhered to the Consolidated Criteria for Reporting Qualitative Studies checklist. Results: In a collaborative project, nurses from the two settings developed nursing services to address signs indicating exacerbation of heart failure and risk of hospital visits, involving advanced heart failure monitoring and treatment in patients' homes. A clinical pathway was developed to assure effective assessment of patients' condition. The home care nurses gained new knowledge and developed work practices that called for different competencies. Access to consultation from specialised heart failure nurses was instrumental in this transition. Conclusions: The development of nursing services by integrating primary and secondary services facilitates translation of knowledge, competencies and understandings between nurses at different settings. Such integration can foster expertise in nursing services. Relevance to clinical practice: The transfer of specialised healthcare services to primary care facilitates collaboration and sharing of knowledge, understanding and work practices. Keywords: advanced practice nurses; competencies; ethnography; expertise; heart failure; home care nurses; integrated services; knowledge; trans-situational.
  • Which data are available in central registries on bladder cancer patients in the five Nordic countries.

    Körner, Stefanie Korsgaard; Dreyer, Thomas; Haug, Erik Skaaheim; Jerlström, Tomas; Boström, Peter J; Gudjonsson, Sigurdur; Jensen, Jørgen Bjerggaard; 1Department of Urology, Aarhus University Hospital, Aarhus, Denmark. 2Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. 3Department of Urology, Vestfold Hospital Trust, Tønsberg, Norway. 4Institute of Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway. 5Department of Urology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. 6Department of Urology, Turku University Hospital, Turku, Finland. 7Department of Urology, Landspitali University Hospital, Reykjavik, Iceland. (Taylor & Francis, 2021-01-28)
    Objective: The aim of this study was to give a collective overview on all available data sources on bladder cancer patients in the Nordic countries including the amount of detail and coverage. Methods: National representatives from five Nordic countries were asked to fill out a questionnaire on available information regarding bladder cancer patients from databases in their respective countries. Additional information was retrieved from descriptions of the relevant registries. Results: Non-muscle invasive bladder cancer: from all countries, information on stage and grade at transurethral resection of the bladder (TURB) could be retrieved. Details on procedures (TURB, instillation therapy, photodynamic diagnosis, and perioperative instillation) were varying within different databases. Muscle invasive bladder cancer: in all Nordic countries, detailed information on cystectomy patients could be retrieved but with variable registration of complications. Completeness of available information on oncological treatment (radiation, chemotherapy, and immunotherapy) were varying. Oncological outcome: Information on overall survival was available in all countries whereas recurrence-free survival and cancer-specific survival were available for some but not all patients depending on treatment modality. Conclusions: Despite limitations, we found that it was possible to retrieve detailed information on diagnostics, treatment, and outcome for most aspects of bladder cancer in the Nordic countries on a population based, non-selected patient cohort. Keywords: Bladder cancer; database; muscle invasive; non-muscle invasive; registry.
  • Case Report: Successful Implementation of Integrative Cognitive Remediation for Early Psychosis.

    Vidarsdottir, Olina G; Roberts, David L; Twamley, Elizabeth W; Gudmundsdottir, Berglind; Sigurdsson, Engilbert; Magnusdottir, Brynja B; 1Department of Psychiatry, Landspitali-The National University Hospital, Reykjavik, Iceland. 2Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland. 3Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States. 4Department of Psychiatry, University of California, La Jolla, CA, United States. 5Center of Excellence for Stress and Mental Health and Research Service, VA San Diego Healthcare System, San Diego, CA, United States. 6Department of Psychology, Reykjavik University, Reykjavik, Iceland. (Frontiers Research Foundation, 2021-01-14)
    Many individuals demonstrate functionally relevant impairment in neurocognition as well as social cognition early on in the course of their psychotic disorder. There is robust evidence supporting cognitive remediation as an effective treatment of cognitive dysfunction in schizophrenia. Increasingly it is accepted that earlier treatment is associated with better outcome and that it is important to systematically assess and treat cognitive dysfunction before the cognitive and functional disabilities are fully realized. However, the clinical availability of these interventions remains sparse. As we move forward with implementing evidence-based interventions into multi-component treatment for early psychosis, it is important to reflect on experience as well as evidence. This case report aims to describe the implementation of an integrative cognitive remediation program in coordinated specialty care (CSC) for early psychosis in Iceland and investigate whether the intervention is sustainable in a CSC setting. Data on the number of patients treated, facilitators trained, groups conducted, and funding was used to assess the sustainability. The results show that since initial implementation in 2016, the intervention has been routinely available as part of standard care, with over 100 patients having received the treatment. The report discusses key factors in the successful implementation of the program. Keywords: compensatory cognitive training; functional outcome; rehabilitation; schizophrenia; social cognition and interaction training.
  • The Expiry of Humira Market Exclusivity and the Entry of Adalimumab Biosimilars in Europe: An Overview of Pricing and National Policy Measures.

    Moorkens, Evelien; Godman, Brian; Huys, Isabelle; Hoxha, Iris; Malaj, Admir; Keuerleber, Simon; Stockinger, Silvia; Mörtenhuber, Sarah; Dimitrova, Maria; Tachkov, Konstantin; et al. (Frontiers Media, 2021-01-08)
    Background: From October 2018, adalimumab biosimilars could enter the European market. However, in some countries, such as Netherlands, high discounts reported for the originator product may have influenced biosimilar entry. Objectives: The aim of this paper is to provide a European overview of (list) prices of originator adalimumab, before and after loss of exclusivity; to report changes in the reimbursement status of adalimumab products; and discuss relevant policy measures. Methods: Experts in European countries received a survey consisting of three parts: 1) general financing/co-payment of medicines, 2) reimbursement status and prices of originator adalimumab, and availability of biosimilars, and 3) policy measures related to the use of adalimumab. Results: In May 2019, adalimumab biosimilars were available in 24 of the 30 countries surveyed. Following introduction of adalimumab biosimilars, a number of countries have made changes in relation to the reimbursement status of adalimumab products. Originator adalimumab list prices varied between countries by a factor of 2.8 before and 4.1 after loss of exclusivity. Overall, list prices of originator adalimumab decreased after loss of exclusivity, although for 13 countries list prices were unchanged. When reported, discounts/rebates on originator adalimumab after loss of exclusivity ranged from 0% to approximately 26% (Romania), 60% (Poland), 80% (Denmark, Italy, Norway), and 80-90% (Netherlands), leading to actual prices per pen or syringe between €412 (Finland) and €50 - €99 (Netherlands). To leverage competition following entry of biosimilar adalimumab, only a few countries adopted measures specifically for adalimumab in addition to general policies regarding biosimilars. In some countries, a strategy was implemented even before loss of exclusivity (Denmark, Scotland), while others did not report specific measures. Conclusion: Even though originator adalimumab is the highest selling product in the world, few countries have implemented specific policies and practices for (biosimilar) adalimumab. Countries with biosimilars on the market seem to have competition lowering list or actual prices. Reported discounts varied widely between countries.
  • Acute upper gastrointestinal bleeding: a population-based, five-year follow-up study.

    Hreinsson, Johann P; Jonsson, Armann; Bjornsson, Einar S; 1Department of Internal Medicine, Section of Gastroenterology and Hepatology, The Sahlgrenska University Hospital, Gothenburg, Sweden. 2Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland. 3Faculty of Medicine, University of Iceland, Reykjavik, Iceland. (Taylor & Francis, 2020-11-23)
    Objective: Data on long-term rebleeding risk and mortality in acute upper gastrointestinal bleeding (AUGIB) patients are scarce and comparison to controls are lacking. Aimsof the study were to assess long-term prognosis of AUGIB patients and compare to controls. Methods: A population-based retrospective case-control study conducted at the National University Hospital of Iceland and included all patients who underwent endoscopy in 2010-2011. AUGIB was defined as haematemesis or coffee ground vomiting leading to hospitalization or occurring in a hospitalized patient. Controls underwent endoscopy in 2010-2011, matched for sex/age. Rebleeding was defined as AUGIB >14 days up to five years after index bleeding. Results: Overall, 303 patients had AUGIB, mean age 67 (±18), controls66 years (±19), females, 51 and 46%, respectively. The five-year rebleeding rate for AUGIB patients was 13% (95%CI 9-17%), higher than the rate of bleeding events in controls, 3% (95%CI 1-5%; log-rank <0.001), hazard ratio (HR) 6.0 (95%CI 2.4-15) when correcting for comorbidities, NSAID's, PPI's and antithrombotics. The mortality of AUGIB patients at end of follow-up was higher when compared to controls, 39% (95%CI 49-33%) vs. 26% (95%CI 30-21%), log-rank <0.001, comorbidity-adjusted HR 1.4 (1.1-1.9). A subanalysis of non-variceal AUGIB yielded similar results in regard to rebleeding and mortality rates. Conclusions: AUGIB patients were at 6-fold risk of rebleeding compared to bleeding events in controls at five years of follow-up. Five-year mortality was higher in AUGIB patients when compared to controls even when correcting for age and comorbidities, suggesting that an episode of AUGIB indicates serious frailty. Keywords: GI-bleeding;; mortality;; outcome;; prognosis;; rebleeding; survival;.
  • Inflammatory hallmarks of lesser prominence in psoriatic arthritis patients starting biologics: a Nordic population-based cohort study.

    Lund Hansen, Rebekka; Schoedt Jørgensen, Tanja; Dreyer, Lene; Hetland, Merete L; Glintborg, Bente; Askling, Johan; Di Giuseppe, Daniela; Jacobsson, Lennart T H; Wallman, Johan K; Nordstrom, Dan; et al. (Oxford University Press, 2021-01)
    Objectives: To assess secular trends in baseline characteristics of PsA patients initiating their first or subsequent biologic DMARD (bDMARD) therapy and to explore prescription patterns and treatment rates of bDMARDs from 2006 to 2017 in the Nordic countries. Methods: PsA patients registered in the Nordic rheumatology registries initiating any treatment with bDMARDs were identified. The bDMARDs were grouped as original TNF inhibitor [TNFi; adalimumab (ADA), etanercept (ETN) and infliximab (IFX)]; certolizumab pegol (CZP) and golimumab (GOL); biosimilars and ustekinumab, based on the date of release. Baseline characteristics were compared for the five countries, supplemented by secular trends with R2 calculations and point prevalence of bDMARD treatment. Results: A total of 18 089 patients were identified (Denmark, 4361; Iceland, 449; Norway, 1948; Finland, 1069; Sweden, 10 262). A total of 54% of the patients were female, 34.3% of patients initiated an original TNFi, 8% CZP and GOL, 7.5% biosimilars and 0.3% ustekinumab as a first-line bDMARD. Subsequent bDMARDs were 25.2% original TNFi, 9% CZP and GOL, 12% biosimilars and 2.1% ustekinumab. From 2015 through 2017 there was a rapid uptake of biosimilars. The total of first-line bDMARD initiators with lower disease activity increased from 2006 to 2017, where an R2 close to 1 showed a strong association. Conclusion: Across the Nordic countries, the number of prescribed bDMARDs increased from 2006 to 2017, indicating a previously unmet need for bDMARDs in the PsA population. In recent years, PsA patients have initiated bDMARDs with lower disease activity compared with previous years, suggesting that bDMARDs are initiated in patients with a less active inflammatory phenotype. Keywords: bDMARDs; international collaborations; prescription patterns; psoriatic arthritis; secular trends of inflammatory hallmarks.
  • Nasal symptoms increase the risk of snoring and snoring increases the risk of nasal symptoms. A longitudinal population study.

    Värendh, Maria; Janson, Christer; Bengtsson, Caroline; Hellgren, Johan; Holm, Mathias; Schlünssen, Vivi; Johannessen, Ane; Franklin, Karl; Storaas, Torgeir; Jõgi, Rain; et al. (Springer, 2021-01-19)
    Purpose: Humans have a preference for nasal breathing during sleep. This 10-year prospective study aimed to determine if nasal symptoms can predict snoring and also if snoring can predict development of nasal symptoms. The hypothesis proposed is that nasal symptoms affect the risk of snoring 10 years later, whereas snoring does not increase the risk of developing nasal symptoms. Methods: In the cohort study, Respiratory Health in Northern Europe (RHINE), a random population from Denmark, Estonia, Iceland, Norway, and Sweden, born between 1945 and 1973, was investigated by postal questionnaires in 1999-2001 (RHINE II, baseline) and in 2010-2012 (RHINE III, follow-up). The study population consisted of the participants who had answered questions on nasal symptoms such as nasal obstruction, discharge, and sneezing, and also snoring both at baseline and at follow-up (n = 10,112). Results: Nasal symptoms were frequent, reported by 48% of the entire population at baseline, with snoring reported by 24%. Nasal symptoms at baseline increased the risk of snoring at follow-up (adj. OR 1.38; 95% CI 1.22-1.58) after adjusting for age, sex, BMI change between baseline and follow-up, and smoking status. Snoring at baseline was associated with an increased risk of developing nasal symptoms at follow-up (adj. OR 1.22; 95% CI 1.02-1.47). Conclusion: Nasal symptoms are independent risk factors for development of snoring 10 years later, and surprisingly, snoring is a risk factor for the development of nasal symptoms. Keywords: Epidemiology; Nasal obstruction; Sleep; Snoring.
  • Walnut Allergy Across Europe: Distribution of Allergen Sensitization Patterns and Prediction of Severity.

    Lyons, Sarah A; Datema, Mareen R; Le, Thuy-My; Asero, Riccardo; Barreales, Laura; Belohlavkova, Simona; de Blay, Frédéric; Clausen, Michael; Dubakiene, Ruta; Fernández-Perez, Cristina; et al. (Elsevier, 2020-09-08)
    Background: Walnut allergy is common across the globe, but data on the involvement of individual walnut components are scarce. Objectives: To identify geographical differences in walnut component sensitization across Europe, explore cosensitization and cross-reactivity, and assess associations of clinical and serological determinants with severity of walnut allergy. Methods: As part of the EuroPrevall outpatient surveys in 12 European cities, standardized clinical evaluation was conducted in 531 individuals reporting symptoms to walnut, with sensitization to all known walnut components assessed in 202 subjects. Multivariable Lasso regression was applied to investigate predictors for walnut allergy severity. Results: Birch-pollen-related walnut sensitization (Jug r 5) dominated in Northern and Central Europe and lipid transfer protein sensitization (Jug r 3) in Southern Europe. Profilin sensitization (Jug r 7) was prominent throughout Europe. Sensitization to storage proteins (Jug r 1, 2, 4, and 6) was detected in up to 10% of subjects. The walnut components that showed strong correlations with pollen and other foods differed between centers. The combination of determinants best predicting walnut allergy severity were symptoms upon skin contact with walnut, atopic dermatitis (ever), family history of atopic disease, mugwort pollen allergy, sensitization to cat or dog, positive skin prick test result to walnut, and IgE to Jug r 1, 5, 7, or carbohydrate determinants (area under the curve = 0.81; 95% CI, 0.73-0.89). Conclusions: Walnut-allergic subjects across Europe show clear geographical differences in walnut component sensitization and cosensitization patterns. A predictive model combining results from component-based serology testing with results from extract-based testing and information on clinical background allows for good discrimination between mild to moderate and severe walnut allergy. Keywords: Allergen components; EuroPrevall; Europe; IgE sensitization; Prediction; Severity; Walnut allergy; iFAAM.

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