Longitudinal development of hand use in children with unilateral spastic cerebral palsy from 18 months to 18 years.

AIM: To describe the development of the use of the affected hand in bimanual tasks in children with unilateral cerebral palsy (CP) from 18 months to 18 years. Specifically, whether early development can be confirmed in a larger cohort and how development progresses during adolescence. METHOD: In total, 171 participants (95 males, 76 females; mean age 3 years 1 month [SD 3 years 8 months], range 18 months-16 years at inclusion) were classified in Manual Ability Classification System (MACS) levels I (n = 41), II (n = 91), and III (n = 39). Children were assessed repeatedly (median 7, range 2-16 times) with the Assisting Hand Assessment: in total 1197 assessments. Developmental trajectories were estimated using a nonlinear mixed effects model. To further analyse the adolescent period, a linear mixed model was applied. RESULTS: The developmental trajectories were different between participants in MACS levels (MACS I-II, II-III) in both rate (0.019, 95% confidence interval [CI] 0.006-0.031, p = 0.034; 0.025, 95% CI 0.015-0.037, p < 0.001) and limit (19.9, 95% CI 16.6-23.3, p = 0.001; 7.2, 95% CI 3.3-11.2, p < 0.003). The individual variations were large within each level. The developmental trajectories were stable over time for all MACS levels between 7 and 18 years (p > 0.05). INTERPRETATION: Children and adolescents with unilateral CP have considerable development at an early age and a stable ability to use their affected hand in bimanual activities from 7 to 18 years in all MACS levels.

Kidney volume, kidney function, and ambulatory blood pressure in children born extremely preterm with and without nephrocalcinosis.

BACKGROUND: Reduced kidney volume (KV) following prematurity is a proxy for reduced nephron number and is associated with the development of hypertension and end-stage renal disease in adults. We investigated whether extreme prematurity affects KV, function, and blood pressure in school-aged children and if nephrocalcinosis (NC) developed during the neonatal period had additional effects. METHODS: We investigated 60 children at a mean age of 7.7 years: 20 born extremely preterm (EPT < 28 weeks gestational age with NC (NC+)), 20 born EPT without NC (NC-), and 19 born as full-term infants (control). We measured KV by ultrasound, collected blood and urine samples to evaluate renal function, and measured office and 24-h ambulatory blood pressure (ABPM). RESULTS: Children born EPT had significantly smaller kidneys (EPT (NC+ NC-) vs control (estimated difference, 11.8 (CI - 21.51 to - 2.09 ml), p = 0.018) and lower but normal cystatin C-based glomerular filtration rate compared with control (estimated difference, - 10.11 (CI - 0.69 to - 19.5), p = 0.035). KV and function were not different between NC+ and NC- groups. Change in KV in relation to BSA (KV/BSA) from the neonatal period to school age showed significantly more EPT children with neonatal NC having a negative evolution of KV (p = 0.01). Blood pressure was normal and not different between the 3 groups. Fifty percent of EPT had a less than 10% day-to-night decline in ABPM. CONCLUSIONS: Kidney growth and volume is affected by EPT birth with NC being a potential aggravating factor. Circadian blood pressure regulation seems abnormal in EPT-born children.

Posttraumatic growth and depreciation six years after the 2004 tsunami.

Background: Posttraumatic growth (PTG) has been reported after various types of potentially traumatic events, as a part of the personal recovery process among survivors. Even negative changes in survivors' life view, known as posttraumatic depreciation (PTD), have been identified as an additional aspect in the personal recovery processes. Objective: To examine how the type of exposure experienced by survivors of a natural disaster, the 2004 Southeast Asia tsunami, influenced self-reported PTG and PTD six years later (T2). Additionally, the study examined the relations between psychological distress and posttraumatic stress symptoms (PTSS) 14 months after the disaster (T1), to PTG and PTD, respectively at T2. Finally, the study examined whether psychological distress and PTSS (T1) could have a mediating effect on PTG and PTD at T2. Method: The participants were 848 tsunami survivors living in Stockholm, Sweden who responded to a questionnaire at 14 months (T1) and six years (T2) after the tsunami. The material was analysed using linear regression and pathway analysis. PTG and PTD were measured on separate scales. Results: The type of exposure was significant related to both PTG and PTD six years later (T2). Those experiencing a combination of various types of exposure (including threat to life and bereavement) reported higher scores for both PTG and PTD. There were significant positive correlations between PTSS at T1 and PTG /PTD at T2, and somewhat lower correlations between psychological distress at T1 and PTG/PTD at T2. Both PTSS and psychological distress at T1 were significant mediating variables for both PTG and PTD at T2. Conclusions: Studying survivors' various types of exposure and subsequent changed view of life - both PTG and PTD - resulted in a broadened understanding of the complexity of reactions and the recovery process among survivors.

A Theory-Based Study of Factors Explaining General Practitioners' Intention to Use and Participation in Electronic Continuing Medical Education.

INTRODUCTION: Electronic modes of continuing medical education (eCME) can provide an appropriate and scalable way of updating the knowledge and skills of general practitioners (GPs). To optimize the adoption of eCME and develop efficient and cost-effective eCME programs, factors explaining GPs' intention to use eCME must first be elucidated. METHODS: Using the Theory of Planned Behavior as a framework, we developed a questionnaire and administered it to GPs in seven CME seminars in Isfahan, Iran, in 2014. Three domains of GPs' intention to use eCME were measured: attitudes, perceived behavioral control, and subjective norms. We used linear and logistic regression to identify the main predictors of intention and behavior. RESULTS: GPs who had high score in perceived behavioral control and a more positive attitude toward e-learning had a higher intention to adopt it for CME. In contrast, subjective norms (eg, social pressures to use eCME) were not a predictor. Attitude toward usefulness of eCME was the main predictor of being an actual eCME user. DISCUSSION: Perceived behavioral control and attitude constitute the main predictors of the intention to use eCME. Establishing discussions forums and strengthening organizational support for eCME through an increased awareness among clinical superiors and CME managers would be expected to increase GPs' intention to use eCME.

Diagnostic utility of musculoskeletal ultrasound in patients with suspected arthritis--a probabilistic approach.

INTRODUCTION: This study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach. METHODS: One hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale. RESULTS: The rheumatologists' certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P <0.001). With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001). MSUS findings agreed with the final diagnosis in 95% of patients. CONCLUSION: Musculoskeletal ultrasound, when added to routine rheumatologic investigation, greatly increases the diagnostic certainty in patients referred for the evaluation of inflammatory arthritis. The changes from pre-test to post-test probability quantify the diagnostic utility of musculoskeletal ultrasound in probabilistic terms.

Statin treatment reduces the risk of hepatocellular carcinoma but not colon cancer-results from a nationwide case-control study in Sweden.

BACKGROUND: Several studies have indicated that statins may have anticarcinogenic effects. The aim of the present study was to investigate if statin treatment was associated with a reduced risk of hepatocellular carcinoma (HCC) or colon cancer. METHODS: A nationwide case-control study was carried out in which all cases of HCC and colon cancer in the Swedish population above 40 years of age between 1 July 2006 and 31 December 2010 were identified in the Swedish Cancer Register. For every case, five controls were selected and matched on age and sex. Data on statin use was extracted from the Swedish Prescribed Drug Register. We estimated risks using conditional logistic regression and adjusted for educational level, concomitant medications and comorbidity. RESULTS: Identified were 3994 cases of HCC and matched with 19.970 controls, and 21.143 cases of colon cancer were identified and matched with 105.715 controls. In the adjusted analysis, the odds ratio (OR) for HCC among statin users was 0.88 (95% confidence interval (CI) 0.81-0.96), and the OR for colon cancer was 1.04 (95%CI 1.00-1.08) compared with non-users. CONCLUSION: Statin use was associated with a modest decreased risk of HCC but did not influence the risk of colon cancer. Future randomized placebo-controlled trials in HCC high-risk patients are warranted to further investigate the possible prophylactic effect of statins in HCC.

Relationship between work context and adherence to a clinical practice guideline for peripheral venous catheters among registered nurses in pediatric care.

BACKGROUND: It is known that registered nurses' (RNs') work context is related to their use of research and that it can affect nurse and patient satisfaction, as well as the outcomes of care. However, little is known about the relationship between work context and nurses' adherence to clinical practice guidelines. The aim of this study was to describe RNs' adherence to a clinical practice guideline (CPG) on the management of peripheral venous catheters (PVCs), their perceptions of work context, and how nurses' work context and characteristics relate to guideline adherence. METHODS: This cross-sectional survey was conducted at a large pediatric university hospital in Sweden. Data were collected through a questionnaire on RNs' adherence to components of a CPG and by using the Alberta Context Tool to assess the nurses' perceptions of work context, including leadership, culture, feedback processes, and other organizational characteristics. RESULTS: Work context--in the form of structural and electronic resources, information sharing activities, and feedback processes--was in different ways associated with the adherence to the CPG components. The RNs' adherence on unit level varied: half the units demonstrated complete adherence on disinfection of hands, whereas a majority of the units reported less than 70% adherence on the use of disposable gloves and the daily inspection of a PVC site. LINKING EVIDENCE TO ACTION: Our findings indicate that components in one CPG might require diverse implementation strategies because they are linked to different contextual factors.

Determinants in adolescence for adult sickness absence in women and men: a 26-year follow-up of a prospective population based cohort (Northern Swedish cohort).

BACKGROUND: To date little is known regarding how factors measured in adolescence predict sickness absence in adulthood, and whether different patterns of factors exist for women and men that could contribute to an explanation of adult gender differences in sickness absence. METHODS: All pupils in the last year of compulsory school in the municipality of Luleå with complete information from surveys (questionnaires) in 1981 and 1983 (compulsory and upper-secondary schooling; 16 and 18 years of age, N=719) were followed with register data on medically certified sickness absence (1993-2007). Generalised linear models were applied to calculate Risk Ratios with 95% Confidence Intervals (CI) comparing annual mean numbers of sickness absence spells in exposed versus unexposed groups. RESULTS: In the multivariate model, the following factors were found to be predictive of future sickness absence in women: participating in an upper secondary school program in 1983 dominated by women (> 60%): 1.41 (95% CI 1.00 - 1.97); sometimes sickness absence from school in 1981: 1.60 (95% CI 1.18 - 2.17) and low parental socioeconomic status in 1981: 2.20 (95% CI 1.44 - 3.38). In men, low school grades in 1981: 4.36 (95% CI 2.06 - 9.22) and fathers not in gainful employment in 1981: 2.36 (95% CI 1.53 - 3.66) were predictive. CONCLUSION: The findings suggest that sickness absence in adulthood is predicted by factors measured in adolescence. These predictors may differ for women and men. For women, early life absence and social environmental factors, for men low achievements at school and lack of employment of their father seem to be predictive.

Support, opinion of support and psychological health among survivors of a natural disaster.

BACKGROUND: Although formal intervention after disasters is recommended, the evidence base for this is weak. Satisfaction with support after disasters is seldom investigated and the relation to psychological symptoms is unknown. AIMS: To investigate whether dissatisfaction with social and formalized support are associated with post-disaster psychological symptoms. METHODS: A total of 1,505 Swedish survivors of the 2004 Indian Ocean tsunami responded to a questionnaire 14 months after the disaster, including the General Health Questionnaire-12, the Impact of Events Scale - Revised, the Crisis Support Scale, and questions concerning the reception and appraisal of social and formalized support from health care, psychological services and insurance agencies. Disaster exposure and background factors were controlled for in the analyses. RESULTS: Reception of formalized support, but not social support, was associated with both psychological distress and post-traumatic stress. Dissatisfaction with social but not formalized support, with the exception of support from insurance agencies, was associated with psychological distress. CONCLUSIONS: Social support and formalized support should be differentiated in future studies in order to improve preventive intervention efforts after disasters. The reporting of dissatisfaction with social support merits special attention, since this may indicate increased risk for psychological symptoms.

Longitudinal course of physical and psychological symptoms after a natural disaster.

BACKGROUND: After disaster, physical symptoms are common although seldom recognized due to lack of knowledge of the course of symptoms and relation to more studied psychological symptoms. OBJECTIVE: This study aimed to investigate the change in the reporting of different physical symptoms after a disaster, including possible factors for change, and whether psychological symptoms predict physical symptoms reporting at a later point in time. METHOD: A longitudinal study of citizens of Stockholm who survived the 2004 Indian Ocean tsunami. A total of 1,101 participants completed questionnaires on somatic symptoms, general distress, posttraumatic stress, exposure, and demographic details 14 months and 3 years after the disaster. Physical symptoms occurring daily or weekly during the last year were investigated in four symptom indices: neurological, cardiorespiratory, gastrointestinal, and musculoskeletal. We used generalized estimating equations (GEE) analysis to determine odds ratios for a change in symptoms, and pathway analysis to predict the influence of psychological symptoms on physical symptoms. RESULTS: There was a general decrease of reporting in all physical symptom indices except the musculoskeletal symptom index. The change in the neurological symptom index showed the strongest association with exposure, and for women. General distress and posttraumatic stress at 14 months postdisaster predicted physical symptoms at 3 years. CONCLUSION: Physical symptoms were predicted by psychological symptoms at an earlier time point, but in a considerable proportion of respondents, physical symptoms existed independently from psychological symptoms. Physicians should be observant on the possible connection of particular pseudoneurological symptoms with prior adversities.

Childhood life events and psychological symptoms in adult survivors of the 2004 tsunami.

BACKGROUND: Negative life events in childhood have an adverse influence on adult psychological health, and increase vulnerability to subsequent potential traumas. It remains unclear whether this is also true in the case of disasters. AIM: This study investigates whether the experience of negative life events in childhood and adolescence was associated with psychological symptoms in groups of Swedish survivors with different types of exposure to the tsunami. METHODS: 1505 survivors from Stockholm responded to a questionnaire on psychological distress, which was sent by post 14 months after the 2004 Indian Ocean tsunami. Psychological distress was measured by General Health Questionnaire-12 and suicidal ideation, and post-traumatic stress was measured by Impact of Event Scale-Revised. Life events prior to age 16 were collected and categorized under the indices accident, violence, loss and interpersonal events. Exposure to the tsunami was categorized in different types, and controlled for in the analyses. RESULTS: With the adjustment for confounders, significant odds ratios were found for all indices on at least one outcome measure, despite the powerful effect of the tsunami. We could not discern any distinct difference in the distribution of the tendency to report the different outcomes depending on types of prior life events. CONCLUSIONS: The implication of the study is that, for adult survivors of disaster, the reporting of adverse life events from childhood may influence future decisions regarding therapy.

Psychological distress and sick leave in Swedish survivors of the 2004 tsunami: a comparison with a population sample.

Disaster studies of the effects of trauma exposure on subsequent psychological health have seldom used population comparisons. A total of 1463 tsunami survivors from Stockholm were categorized according to type of exposure, and compared on measures of General Health Questionnaire and sick leave, with a matched population-based sample of 12,045 individuals from the same region. Data from the survivor group were obtained through a postal questionnaire 14 months postdisaster. Data from the population sample were collected in the same year. In comparison to the population sample, levels of sick leave ranged from higher in multiply exposed groups to lower in the least exposed group. For psychological distress, levels in multiply and moderately exposed groups were higher, and in lower exposed groups comparable. The use of a population comparison resulted in a support of recent research showing a relative resiliency of survivors exposed during disaster to potential trauma of lesser severity.

The role of pain-mediating sensory nerves in histamine-induced inflammation of nasal mucosa.

Topical application of histamine on the nasal mucosa causes an inflammatory reaction with increased mucosal swelling and perfusion. In the nasal mucosa histamine receptors are found in the vascular epithelium and at free sensory nerve endings. The aim of this randomized double-blind placebo controlled study was to investigate if this inflammatory reaction to locally administered histamine was dependent upon the stimuli of pain-mediating sensory nerves, or if it mainly was the result of direct stimuli of the vascular epithelium. Eighteen healthy non-allergic subjects were treated with sprays of lidocaine or saline (placebo) in the nose, followed by challenge with histamine. Using a cross-over design the participants later returned and were allocated to the opposite treatment followed by histamine. Nasal congestion, and concentration, velocity and perfusion of erythrocytes were measured with rhinostereometry and laser Doppler flowmetry. Symptoms of blockage, discharge and itching were scored. When comparing the lidocaine group to the placebo group, we found no significant differences in the reaction to histamine concerning any of the measured parameters or subjective symptoms. In conclusion, our results suggest that the stimuli of pain-mediating sensory nerves do not significantly contribute to the inflammatory effect of histamine on human nasal mucosa.

Different types of exposure to the 2004 tsunami are associated with different levels of psychological distress and posttraumatic stress.

The impact of traumatic exposure on psychological distress and posttraumatic stress was investigated at 14 months through self-report in 1,505 Swedish tourists who survived the 2004 Indian Ocean Tsunami. Exposure, differentiated in single and multiple types, was associated with different levels of impaired mental health measured by General Health Questionnaire (GHQ) and Impact of Event Scale-Revised (IES-R). Additionally, having sole exposure to subjective life threat brought about specific psychological effects. Some demographic factors are associated with outcome on either the GHQ or the IES-R. Identifying specific types of exposure of disaster survivors may be a way to identify individuals who could be screened for psychological ill health at a later point in time.

Tube associated otorrhea in children with recurrent acute otitis media; results of a prospective randomized study on bacteriology and topical treatment with or without systemic antibiotics.

OBJECTIVE: To establish if otorrhea associated to tympanostomy tubes in infants suffering from recurrent acute otitis media is similar to acute otitis media, and if topical treatment alone is sufficient or if addition of systemic antibiotics is required. METHODS: Children under 3 years of age with tympanostomy tubes due to recurrent acute otitis media were recruited to the study. The study design was open label randomized and prospective. Fifty patients were allocated to either of two treatment groups and were monitored for 6 months. Group I received only topical treatment (commercially available ear drops and saline solution) in case of otorrhea. Group II was treated with topical treatment together with systemic antibiotics. All episodes of acute otorrhea were registered. Main outcome measure was duration of otorrhea in days. Bacterial samples from the ear discharge were taken. RESULTS: Forty-one episodes were treated according to protocol. The bacteriological testing mainly showed bacteria typical of acute otitis media. A majority of episodes were cured within 7 days in both groups, and statistical analysis showed no significant difference between the treatment groups in duration of otorrhea. In Group I systemic antibiotics were added in one-third (7/21) of the episodes due to signs of affected general condition such as high fever and severe earache. CONCLUSIONS: The otorrhea episodes in the study were similar to acute otitis media based on the bacteriological results. Topical treatment alone might be used as first treatment of choice. Although systemic antibiotics were added in several cases in the topical treatment group, the findings of the study do not support use of systemic antibiotics for tube associated otorrhea in RAOM children in general.

Aire-deficient mice develop hematopoetic irregularities and marginal zone B-cell lymphoma.

Autoimmune polyendocrine syndrome type I (APS I) is an inherited recessive disorder with a progressive immunological destruction of many tissues including the adrenal cortex, the parathyroid glands, and the gonads. APS I is caused by mutations in the AIRE gene (autoimmune regulator), expressed in cells of the thymus and spleen, suggesting a role in central and peripheral tolerance. Aire(-/-) mice replicate the autoimmune features of APS I patients with the presence of multiple autoantibodies and lymphocytic infiltrates in various tissues, but young mice appear clinically healthy. We here report the investigation of 15- to 24-month-old Aire(-/-) mice. We did not observe any endocrinological abnormalities, nor did sera from these mice recognize known APS I autoantigens. Interestingly, however, there was a high frequency of marginal zone B-cell lymphoma in Aire(-/-) mice and liver infiltrates of B cells, suggesting chronic antigen exposure and exaggerated activation. Furthermore, increased numbers of monocytes in blood were identified as well as augmented numbers of metallophilic macrophages in the spleen. We propose that Aire, in addition to its function in the thymus, also has a peripheral regulatory role by controlling the development of antigen-presenting cells (APCs) and marginal zone B-cell activation.

Outcome of traumatic brain injuries in 1,508 patients: impact of prehospital care.

This article describes the outcome of 1,508 patients with traumatic brain injuries (TBI) treated in a single neurosurgical unit over an 8-year period. Our aim has been to compare those outcomes with our previous results and with other large patient series. Another important goal was to evaluate the effect of the introduction of a 4-year ongoing study initiated in January 1993 using a new strategy of prehospital care on postresuscitation Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS). Results from the 1,508 patients showed good recovery or moderate disability in 69%, severe disability or vegetative state in 11%, and a mortality rate of 20%. When outcome of the most severely injured patients (GCS < or = 8) was compared with those of our previous and other large international patient series, more favorable outcome figures were shown in the present study. To evaluate the impact of the improved prehospital care after half of the study period, a logistic regression analysis showed after January 1993 a significantly increased expected odds/ratio for a postresuscitation GCS 8-15 rather than a GCS 3-4 (odds/ratio: 2.2; p < 0.001). For patients with postresuscitation GCS 5-7 and 8-15, the expected odds/ratio for a GOS 4-5 instead of GOS 1 increased significantly (odds/ratio: 2.2 and 1.7, respectively; p < 0.05-0.01). For patients with GCS 3-4, an increased expected odds/ratio (2.0; p < 0.05) for a GOS 2-3 rather than a GOS 1 was seen. The principal conclusion is that outcome for the severely injured patients in the present study is more favorable than in other large series of TBI. We posit that the introduction of effective prehospital care most likely contributed to the improved postresuscitation neurological status and consequently to the better outcome observed after January 1993.