Childhood atopic dermatitis is associated with cardiovascular risk factors in young adulthood-A population-based cohort study.

BACKGROUND: Studies have indicated that atopic dermatitis (AD) is associated with an increased risk of cardiovascular disease (CVD). However, data are conflicting. Furthermore, the longitudinal effect of childhood AD on cardiovascular risk factors in young adulthood is less investigated. OBJECTIVES: To assess associations between AD in childhood and CVD risk factors in young adulthood. METHODS: The study encompasses longitudinal data from a population-based birth cohort. Participants with data up to age 24 years were included (n = 2270). The primary outcomes were body mass index (BMI), waist circumference (WC), body fat per cent (BF%) and blood pressure (BP) at 24 years. The secondary outcome was blood lipids. Severe AD was defined as AD in combination with sleep disturbance due to itching. RESULTS: In total, 18.6% (n = 420) had AD at 24 years. Males with AD had higher BMI (ßAdj. 0.81, 95% CI 0.15-1.47), BF% (ßAdj. 1.19, 95% CI 0.09-2.29), systolic BP (ßAdj. 1.92, 95% CI 0.02-3.82), total cholesterol (ßAdj. 0.14, 95% CI 0.00-0.28) and LDL cholesterol (ßAdj. 0.15, 95% CI 0.02-0.27) compared with males without AD. No associations were seen in females. Current AD with prepubertal onset was associated with increased BMI in both males (ßAdj. 0.89, 95% CI 0.11-1.67) and females (ßAdj. 0.72, 95% CI 0.11-1.33). At 24 years, 23.1% (n = 97) of all with AD, had severe disease, which was significantly associated with overweight in both sexes, with BMI (ßAdj. 1.83, 95% CI 0.72-2.94), WC (ßAdj. 4.03, 95% CI 1.54-6.52) and BF% (ßAdj. 2.49, 95% CI 0.60-4.39) in females and with BF% (ßAdj. 2.96, 95% CI 0.23-5.69) in males, compared with peers with mild to moderate AD. CONCLUSION: AD in males appears to be associated with CVD risk factors in young adulthood. The duration and severity of AD seem to be of importance in both sexes.

Prevalence and characteristics of atopic dermatitis among young adult females and males-report from the Swedish population-based study BAMSE.

BACKGROUND: There is limited knowledge regarding prevalence and characteristics of atopic dermatitis (AD) among young adults in the general population. OBJECTIVES: To study AD among young adults in a Swedish population-based birth cohort, with a particular focus on prevalence, sex differences including risk for AD at different ages, disease course and characteristics of AD at 24 years. METHODS: The BAMSE cohort includes 4089 individuals who have been followed regularly from birth to age 24 years regarding AD and atopic diseases. For this study 3055 individuals who answered questions regarding AD at the 24-year follow-up were included. All were invited to a clinical examination including skin examination, evaluation by William's criteria and collection of blood for analysis of specific IgE, and 2264 individuals chose to participate. RESULTS: At 24 years, the 12-month prevalence of AD was 17.8% and more females than males had AD (20.5% vs. 14.8%), P < 0.0001. The point prevalence of ongoing AD at clinical examination was 8.0%. AD severity as assessed by Patient-Oriented Eczema Measure (POEM) did not differ between sexes. The proportion of adult onset of AD was 16.9% (92 of 543), females 17.3% vs. males 16.4%. More females than males with AD at 24 years reported disturbed sleep due to itch (26.1% vs. 15.5%, P < 0.003). IgE sensitization was less common among females with AD than males with AD (61.3% vs. 79.6%, P < 0.0001). In addition, male sex (female sex being the reference) was associated with increased odds for AD the first year of life (OR: 1.31, 95% CI; 1.10-1.56), and decreased odds of AD in adolescence and young adulthood (OR: 0.66, 95% CI; 0.55-0.80). CONCLUSIONS: Atopic dermatitis is a common disease among young adults, and even though more females than males have AD at 24 years, adult onset of AD seems to be equally prevalent among both sexes in young adulthood.

Association between atopic dermatitis and autoimmune diseases: a population-based case-control study.

BACKGROUND: Atopic dermatitis (AD) is a common chronic skin disorder and is well known to be associated with other atopic conditions. There is increasing evidence for an association also with nonatopic conditions, including autoimmune diseases, but data are limited about several autoimmune diagnoses. OBJECTIVES: To investigate the association between AD and autoimmune diseases. METHODS: This case-control study used Swedish national healthcare registers. The source population comprised the entire Swedish population aged ≥ 15 years from 1968 to 2016. Cases, including all those with an inpatient diagnosis of AD (from 1968) and/or a specialist outpatient diagnosis of AD (from 2001), were matched by sex and age to healthy controls (104 832 cases of AD, 1 022 435 controls). RESULTS: AD was significantly associated with one or more autoimmune diseases compared with controls - adjusted odds ratio (aOR) 1·97, 95% confidence interval (CI) 1·93-2·01 - and this association was significantly stronger in the presence of multiple autoimmune diseases compared with only one. The association was strongest for autoimmune disorders involving the skin (aOR 3·10, 95% CI 3·02-3·18), the gastrointestinal tract (aOR 1·75, 95% CI 1·69-1·82) or connective tissue (aOR 1·50, 95% CI 1·42-1·58). In the overall analysis, men with AD had a stronger association with rheumatoid arthritis and coeliac disease than did women with AD. In subanalyses, the findings remained stable in multivariable analyses after adjustment for smoking and parental autoimmune disease. CONCLUSIONS: This large population-based study indicates significant autoimmune comorbidity of adults with AD, especially between AD and autoimmune dermatological, gastrointestinal and rheumatological diseases. Having multiple autoimmune diseases resulted in a stronger association with AD than having only one autoimmune disease.

Atopic dermatitis at preschool age and contact allergy in adolescence: a population-based cohort study.

BACKGROUND: Atopic dermatitis (AD) is characterized by an impaired skin barrier, which can allow enhanced penetration of allergens. It is not clear whether AD influences the risk of developing contact allergy. OBJECTIVES: To examine the association between AD at preschool age and contact allergy at 16 years of age. METHODS: At 16 years of age, 2215 adolescents from the population-based cohort BAMSE were included. These adolescents had been followed with repeated questionnaires regarding AD throughout childhood, and contact allergy was assessed by skin patch test at 16 years. RESULTS: AD at preschool age was associated with contact allergy to at least one of the tested substances at 16 years of age among boys [adjusted odds ratio (OR) 1·51, 95% confidence interval (CI) 1·03-2·20] but not among girls (adjusted OR 0·77, 95% CI 0·54-1·10). AD at preschool age was not associated with contact allergy to nickel in either boys or girls. In contrast, AD at preschool age was associated with contact allergy to fragrance mix I (adjusted OR 3·10, 95% CI 1·66-5·80). This association was observed especially for AD at preschool age in combination with IgE sensitization to airborne or food allergens (adjusted OR 3·80, 95% CI 1·67-8·61). CONCLUSIONS: The results suggest that AD in early childhood may be associated with contact allergy to fragrances, but not to nickel, in adolescence.

Use of emollients and topical glucocorticoids among adolescents with eczema: data from the population-based birth cohort BAMSE.

BACKGROUND: Knowledge regarding how adolescents treat their eczema is sparse. OBJECTIVES: To explore the use of emollients and topical glucocorticoids in adolescents with eczema in relation to sex and disease severity, and to study dispensing patterns of topical glucocorticoids. METHODS: Questionnaire-based data on symptoms of eczema, eczema severity and treatment with emollients and topical glucocorticoids were obtained from 3108 adolescents in the Swedish population-based birth cohort BAMSE. Severity of reported eczema was evaluated with the BAMSE Eczema Severity Score (BESS) in a questionnaire and with the Patient-Oriented Eczema Measure in clinically examined patients with current eczema (n = 247). Information on dispensed topical glucocorticoids was obtained from the Swedish Prescribed Drug Register. RESULTS: In all, 10% of the adolescents reported eczema in the preceding year: 73% mild, 17% moderate and 10% severe according to BESS. Almost all used emollients, whereas use of topical glucocorticoids was reported by 55%, with no significant difference between sexes. The likelihood of treatment with emollients and topical glucocorticoids increased when the adolescents had symptoms of current eczema [adjusted odds ratio (OR) 5·95, 95% confidence interval (CI) 1·90-18·8], but not if they had more severe eczema compared with mild eczema (adjusted OR 1·57, 95% CI 0·58-4·25). Among those with reported eczema, 24% had a topical glucocorticoid dispensed in the preceding year, and among those with moderate-to-severe current eczema 24% had a dispensed potent topical glucocorticoid. CONCLUSIONS: This population-based study indicates that adolescents with eczema are undertreated or completely untreated, even those with severe eczema.

Outcomes of Left Heart Bypass Versus Circulatory Arrest in Elective Open Surgical Descending and Thoraco-abdominal Aortic Repair.

OBJECTIVES: To compare early (30 day mortality and major complications) and midterm (survival) outcomes in elective open surgical descending and thoraco-abdominal aortic repair using left heart bypass (LHB) versus hypothermic circulatory arrest (HCA) for organ protection, hypothesising non-inferiority of HCA management. METHOD: This was a retrospective clinical cohort study with cross sectional follow-up. All elective (n = 90) descending or thoraco-abdominal aortic repairs performed between 2004 and 2015 using either LHB (n = 57) or HCA (n = 33) were included. Pre- and intra-operative variables were evaluated by univariate statistical analysis. Thirty day and follow-up mortality were primary endpoints; major complications were secondary endpoints. Propensity score matching was employed to adjust for selection bias. Kaplan-Meier methods were used to estimate midterm survival. RESULTS: Overall 30 day mortality was 8/90 (8.9%): 6/57 (10.5%) using LHB vs. 2/33 (6.1%) using HCA, p = .47. Five patients (5.6%) suffered paraplegia: 3/57 (5.3%) using LHB vs. 2/33 (6.1%) using HCA, p = .87. Stroke occurred in 6/57 (11%) vs. 2/33 (6.1%), p = .76; renal failure in 27/57 (47%) vs. 19/33 (58%), p = .90; and respiratory failure in 17/57 (30%) vs. 11/33 (33%), p = .68. In 26 propensity score matched pairs, findings remained unaltered. Total follow-up was 443 patient years (median 4.9 years). Estimated survival was 78% at 1 year and 77% at 5 years in LHB vs. 72% and 67%, respectively, with HCA; there were no significant inter-group differences, before or after propensity score matching. CONCLUSIONS: In elective descending or thoraco-abdominal aortic repair, no statistically significant differences in 30 day mortality, major complications, or follow-up survival were found when LHB and HCA were compared. These findings remained after propensity score matching.

Editor's Choice - Dual Antiplatelet Therapy Improves Outcome in Diabetic Patients Undergoing Endovascular Femoropopliteal Stenting for Critical Limb Ischaemia.

OBJECTIVE: The purpose of this study was to analyse the effect of dual antiplatelet therapy (DAPT) compared to aspirin on outcome after endovascular interventions in patients with CLI. METHODS: This was a population based retrospective nationwide cohort analysis. Several linked national databases in Sweden: Swedish National Vascular Registry, Prescribed Drug Registry and National Discharge Registry. A total of 1941 patients (median age 79; range 43-103 years; women 58%) were identified with CLI who had undergone primary femoropopliteal endovascular intervention between 2006 and 2012. Of these, 599 (31%) patients were treated after the intervention with DAPT (aspirin and clopidogrel) and 1342 (69%) patients were treated with aspirin only. Percutaneous transluminal angioplasty (PTA) was performed in 1131 patients (58%), stenting in 633 patients (33%), and subintimal angioplasty (SAP) in 177 patients (9%). RESULTS: DAPT was given after PTA, stenting, and SAP to 17% (n = 188), 53% (n = 334), and 44% (n = 77) of the patients, respectively. During the study period, 77 patients (13%) with DAPT and 228 patients (17%) with aspirin underwent a major amputation. Patients receiving DAPT after stenting had a lower rate of amputation (HR 0.56; 95% CI 0.36-0.86) than patients receiving aspirin alone. In the subgroup analysis, the protective effect of DAPT on amputation seemed to be confined to patients with diabetes mellitus receiving a stent (HR 0.26; 95% CI 0.13-0.52; p < .001). DAPT after PTA or SAP did not influence limb salvage, and there was no overall difference in mortality. There was no significant difference in bleeding complications between DAPT and aspirin. CONCLUSION: DAPT with aspirin and clopidogrel compared to aspirin alone was associated with a lower amputation rate but not a higher bleeding rate in patients with diabetes and CLI after endovascular femoropopliteal stenting.

Extracorporeal membrane oxygenation improves coagulopathy in an experimental traumatic hemorrhagic model.

PURPOSE: Hemorrhage is the most common cause of preventable death after trauma. Coagulopathy plays a central role in uncontrolled bleeding and is caused by multiple factors. Extracorporeal Membrane Oxygenation (ECMO) is an established treatment for patients with respiratory failure and has in recent years also been used in severely injured trauma patients with cardiopulmonary failure and coexisting bleeding shock. The aim of this study was to evaluate the effect of ECMO on hypothermia, acidosis, and coagulopathy in a traumatic hemorrhagic rabbit model. METHODS: After anesthesia and tracheostomy, ten New Zealand White rabbits sustained laparotomy, bilateral femur fractures and were hemorrhaged 45% of their estimated blood volume. After 90 min of hemorrhagic shock they were resuscitated with a standard transfusion protocol together with venoarterial ECMO (n = 5) or with a standard transfusion protocol only (n = 5) for 60 min. No systemic heparin was administered. RESULTS: ECMO during 60 min of resuscitation significantly increased heart rate (p = 0.01), mean arterial pressure (p = 0.01), body temperature (p = 0.01) and improved the metabolic acidosis, pH (p = 0.01), and lactate (p = 0.01). ECMO also improved the coagulation capacity measured in vitro by Rotational Thromboelastometry with a significant decrease in clot formation time (p < 0.01). This finding was confirmed in vivo with a significant reduction in the animals' ear bleeding time (p < 0.01) and cuticle bleeding time (p < 0.01); 5/5 animals survived in the ECMO group and 3/5 animals survived in the control group. CONCLUSIONS: Heparin-free ECMO stabilizes circulation, improves coagulation, and may impact short-time survival, during the first 60 min, in an experimental traumatic model with severe hemorrhagic shock.

Massive Blood Transfusion in Patients with Ruptured Abdominal Aortic Aneurysm.

OBJECTIVES: The aim was to study blood transfusions and blood product ratios in massively transfused patients treated for ruptured abdominal aortic aneurysms (rAAAs). METHODS: This was a registry based cohort study of rAAA patients repaired at three major vascular centres between 2008 and 2013. Data were collected from the Swedish Vascular Registry, hospitals medical records, and local transfusion registries. The transfusion data were analysed for the first 24 h of treatment. Massive transfusion (MT) was defined as 4 or more units of red blood cell (RBC) transfused within 1 h, or 10 or more RBC units within 24 h. Logistic regression was used to calculate the odds ratio of 30 day mortality associated with the ratios of blood products and timing of first units of platelets (PLTs) and fresh frozen plasma (FFP) transfused. RESULTS: Three hundred sixty nine rAAA patients were included: 80% men; 173 endovascular aneurysm repairs (EVARs) and 196 open repairs (ORs) with median RBC transfusion 8 units (Q1-Q3, 4-14) and 14 units (Q1-Q3, 8-28), respectively. A total of 261 (71%) patients required MT. EVAR patients with MT (n = 96) required less transfusion than OR patients (n = 165): median RBC 10 units (Q1-Q3, 6-16.5) vs. 15 units (Q1-Q3, 9-26) (p = .002), FFP 6 units (Q1-Q3, 2-14.5) vs. 13 units (Q1-Q3, 7-24) (p < .001), and PLT 0 units (Q1-Q3, 0-2) vs. 2 units (Q1-Q3, 0-4) (p = .01). Median blood product ratios in MT patients were FFP/RBC (EVAR group 0.59 [0.33-0.86], OR group 0.84 [0.67-1.2]; p < .001], and PLT/RBC (EVAR 0 [0-0.17], OR 0.12 (0-0.18); p < .001]. In patients repaired by OR a FFP/RBC ratio close to 1 was associated with reduced 30 day mortality (p = .003). The median PLT/RBC ratio was higher during the later part of the study period (p < .001, median test), whereas there was no significant difference in median FFP/RBC ratio (p = .101, median test). CONCLUSION: The majority of rAAA patients undergoing EVAR required MT. EVAR patients treated with MT had lower FFP/RBC and PLT/RBC ratios than OR patients with MT. The mortality risk was lower with FFP/RBC ratio close to 1:1 in open repaired patients requiring MT. The 24 h PLT/RBC ratio increased over the study period.

The tight junction gene Claudin-1 is associated with atopic dermatitis among Ethiopians.

BACKGROUND: The strong association between epidermal barrier gene variants and Atopic Dermatitis (AD) highlights that impaired skin barrier is a key feature in the pathogenesis of AD. Although the filaggrin (FLG) gene is the major AD risk gene in European and Asian populations, disease-associated variants remain elusive in African populations. OBJECTIVE: A previous study has reported that variants in the tight junction gene CLDN1 have been associated with AD susceptibility and disease severity in African-Americans. Our aim was therefore to investigate the association of CLDN1 with AD in the Ethiopian population. METHODS: To investigate how CLDN1 variants may be involved in increasing the risk of AD in the Ethiopian population, we analysed whole exome sequencing (WES) data for all exons in CLDN1, and in addition, assayed four SNPs (rs17501010, rs9290927, rs9290929 and rs893051) which had previously showed association in African-American AD patients. RESULTS: No damaging variants were detected through WES in 22 Ethiopian samples. Genotyping of disease-associated CLDN1 SNPs in Ethiopian cases and control material showed no overall association. However, significant association was seen for rs893051 in patients who developed AD before the age of 5 years (P < 0.03). CONCLUSION: Taken together, we demonstrate that tight junction genes and, in particular, CLDN1 rather than variants in FLG may be involved in the susceptibility of AD in the Ethiopian population.

Safety of Intra-arterial Catheter Directed Thrombolysis: Does Level of Care Matter?

OBJECTIVES: The aim was to assess whether the level of care influenced the safety related outcomes of catheter directed thrombolysis (CDT) for patients presenting with limb ischaemia and dialysis access thrombosis. METHODS: This was a retrospective cohort study. All consecutive patients at two tertiary referral centres for vascular surgery undergoing CDT for limb ischaemia and dialysis access thrombosis (N = 252) between 2012 and 2014 were included. Patients at Centre 1 were cared for on a general vascular ward and patients at Centre 2 were kept on a post-operative recovery unit with an increased level of care including invasive haemodynamic monitoring. Patient medical records were retrospectively scrutinised and data collected on comorbidities, anti-thrombotic medication, indications for CDT, technical success of CDT, bleeding and non-bleeding related complications, and transfer to a higher level of care. RESULTS: There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding (p = .002) but there was no difference in major bleeding (p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04-9.8, p = .04). CONCLUSIONS: CDT may be undertaken outside of a high dependency setting without a significantly increased risk of complications. Pre-existing cardiac disease was an independent risk factor for transfer to a higher level of care. These findings could have an implication for the clinical cost-effectiveness of CDT.

Incidence of Healthcare Associated Infections After Lower Extremity Revascularization Using Antibiotic Treatment as a Marker.

OBJECTIVE/BACKGROUND: This register based study aimed to investigate the rate and pattern of healthcare associated infections (HCAI) in patients treated for lower extremity arterial disease, using antibiotic prescription as a surrogate for post-operative HCAI. METHODS: A retrospective analysis of prospectively registered data on all patients treated with primary elective, open or endovascular, surgery for lower extremity arterial disease in Sweden between 2005 and 2010, was carried out. Antibiotic prescriptions were determined for three time periods (6 months pre-operative; 30 day post-operative, and 5 months extended post-operative). RESULTS: The cohort (n = 9894) included patients with claudication (27%, n = 2659), critical limb ischemia (rest pain without ulceration; 17%, n = 1681), and ulceration/gangrene (56%, n = 5552). Fifty-nine percent (n = 5865) of the procedures were endovascular interventions. The incidence of 30 day post-operative antibiotic prescriptions was 33% (n = 3294). These were comprised of antibiotics for skin and soft tissue infections (67%, n = 2199); urinary tract infections (UTIs; 21%, n = 703); and respiratory tract infections (12%, n = 383). There was a 92% increase in the antibiotic prescription incidence rate for the 1 month post-operative period compared with the pre-operative period (p < .001). In the endovascular group, UTI antibiotics dominated the 30 day post-operative period for patients with claudication (p < .001). CONCLUSION: Antibiotic treatment can be a useful marker for post-discharge surveillance of HCAI in patients with lower extremity arterial disease. The incidence of post-operative HCAI after lower extremity revascularization may have previously been underestimated.

IgE antibodies in relation to prevalence and multimorbidity of eczema, asthma, and rhinitis from birth to adolescence.

BACKGROUND: Eczema, asthma, and rhinitis affect a large proportion of children, but their prevalence varies with age. IgE antibodies are also common in the pediatric population. However, the links between IgE, disease, and trajectories are unclear. OBJECTIVE: To better understand the links between sensitization and disease, we studied IgE sensitization ever in relation to eczema, asthma, and rhinitis, in children followed up to 16 years of age. METHODS: From the Swedish population-based birth cohort BAMSE, 2607 children were included. Parental reports from six time points between 1 and 16 years were used to identify children with eczema, asthma, and rhinitis. Blood was collected at 4, 8, and 16 years, and sensitization ever was defined as allergen-specific IgE ≥0.35 kUA /l to common food and/or inhalant allergens at any time point. Odds ratios for eczema, asthma, rhinitis, and multimorbidity in relation to sensitization ever were calculated using generalized estimating equations. RESULTS: Fifty-one percent were sensitized at least once up to 16 years. Almost a quarter of ever-sensitized children did not have any disease. After adjustment for potential confounders, sensitization ever was significantly associated with the following: (i) eczema throughout childhood, (ii) multimorbidity of eczema, asthma, and rhinitis from 1 to 16 years (OR for multimorbidity: 5.11, 95% CI: 3.99-6.55), (iii) asthma and rhinitis from 4 to 16 years of age. CONCLUSIONS: Specific IgE is strongly associated with eczema and allergic multimorbidity throughout childhood and with asthma and rhinitis from age 4 years. However, 23% of the children with IgE sensitization do not develop any disease in childhood.

Hand eczema and atopic dermatitis in adolescents: a prospective cohort study from the BAMSE project.

BACKGROUND: There is a well-known association between atopic dermatitis (AD) and hand eczema but less is known about how age at onset, persistence and severity of AD influence the risk of developing hand eczema. OBJECTIVES: To examine the role of AD in the occurrence of hand eczema in adolescence. In addition, associations between asthma and rhinoconjunctivitis, sensitization to common airborne and food allergens, and hand eczema were studied. METHODS: From the population-based birth cohort BAMSE, 2927 adolescents who had been followed up repeatedly concerning allergy-related disease were included. Questionnaires identified adolescents with hand eczema at 16 years, and their blood was analysed for specific IgE. RESULTS: A total of 152 (5·2%) adolescents had hand eczema at the age of 16 years. Many of these adolescents had a history of AD (n = 111; 73·0%) and asthma and/or rhinitis (n = 83; 54·6%), respectively. Children with AD (aged 0-16 years) had more than threefold increased odds ratios (OR) for having hand eczema; those with persistent or severe AD had a crude OR of 6·1 [95% confidence interval (CI) 4·0-9·1] and 5·3 (95% CI 2·9-9·6), respectively. CONCLUSIONS: We confirm a strong association between AD during childhood and hand eczema in adolescence. Children with persistent or more severe AD are at greater risk of developing hand eczema. Asthma and/or rhinoconjunctivitis, positive specific IgE or age at onset of AD are not associated with hand eczema in adolescence.

Atopic and nonatopic eczema in adolescence: is there a difference?

BACKGROUND: There is limited information on clinical manifestations of atopic eczema (AE) and non-AE in teenagers. OBJECTIVES: To describe the characteristics of adolescent eczema in the general population and to identify potential differences between AE and non-AE in teenagers. METHODS: Overall, 3108 teenagers were included from the population-based BAMSE cohort and 2529 of these teenagers provided blood samples for analysis of specific IgE. At age 16 years, the teenagers answered questionnaires regarding the symptoms of eczema, asthma and rhinitis for the previous year. RESULTS: The prevalence of eczema in adolescence was 9·6% (n = 297). More girls than boys had eczema (12·5% vs. 6·5%; P < 0·001). The age at onset was usually within the first 2 years of life (48·8%), but onset in adolescence was also common (25·6%). Eczema was mild in 72·7% of cases, moderate in 16·8% and severe in 10·4%. Body folds were most frequently affected (73·4%). More than half of the teenagers with eczema had AE (59%). The teenagers with AE had more severe and more chronic eczema. Onset in infancy was most common in AE and onset in adolescence was most common in non-AE. There were no major differences in location or seasonal variance between AE and non-AE in adolescence. CONCLUSIONS: AE is more common than non-AE among teenagers. More than one in four teenagers with eczema has moderate-to-severe disease. Onset in adolescence is common, especially for non-AE. AE in adolescence has an earlier onset and is more chronic and more severe than non-AE.

Editor's choice - Safety of carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke: a case-controlled multicentre registry study.

OBJECTIVE: Few studies have been published on the safety of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT). Registry reports have been recommended in order to gather large study groups. DESIGN: A retrospective, registry based, case controlled study on prospectively gathered data from Sweden, the capital region of Finland, and from Denmark, including 30 days of follow up. METHODS: The study group was a consecutive series of 5526 patients who had CEA for symptomatic carotid artery stenosis during a 4.5 year period. Among these, 202 (4%) had IVT prior to surgery, including 117 having CEA within 14 days, and 59 within 7 days of thrombolysis. IVT as well as CEA were performed following established guidelines. The median time from index symptom to CEA was 12 days (range 0-130, IQR 7-21). RESULTS: The 30 day combined stroke and death rate was 3.5% (95% CI 1.69-6.99) for those having IVT + CEA, 4.1% (95% CI 3.46-4.39) for those having CEA without previous IVT (odds ratio 0.84 [95% CI 0.39-1.81]), 3.4% (95% CI 1.33-8.39) for those having IVT + CEA within 14 days, and 5.1% (95% CI 1.74-13.91) for those having IVT + CEA within 7 days. CONCLUSION: Data on the time from symptoms to CEA in patients not having IVT, Rankin score, degree of stenosis, and cerebral imaging were not available. Despite its weaknesses, this study reasserts that CEA can be performed within the recommended 2 weeks of the onset of symptoms and IVT without increasing the risk of peri-operative stroke or death. Centres and vascular registries are recommended to continue monitoring changes in patient characteristics, lead times, and major complications after CEA in general, with a special focus on those who have undergone a prior thrombolysis.

Prevalence and incidence of hand eczema in adolescence: report from BAMSE--a population-based birth cohort.

BACKGROUND: BAMSE is a Swedish population-based birth cohort. OBJECTIVES: To estimate prevalence proportions and the incidence rate of hand eczema in Swedish adolescents, and to compare information given by adolescents and parents. Further aims were to study sex distribution, age at onset and extension of hand eczema. METHODS: At 16 years of age, 2927 adolescents were included in this study; both adolescent and parental questionnaires were used, as well as clinical examination. RESULTS: The 1-year prevalence of hand eczema was 5·2% (n = 152) and 4·0% (n = 116) (P < 0·03), and lifetime prevalence was 9·7% (n = 284) and 7·0% (n = 206) (P < 0·01), respectively, when adolescents and parents reported. The incidence rate was 573/100 000 person-years according to the adolescent report. The level of agreement between adolescents and parents was fair for 1-year and lifetime prevalence (κ = 0·56 and κ = 0·49, respectively). According to the Hand Eczema Extent Score, 27·0% (n = 36) had moderate-to-severe hand eczema. CONCLUSIONS: At the age of 16 years, the 1-year prevalence of hand eczema was substantial, with an incidence rate of the same magnitude as in adults. Female predominance was seen in adolescence. It is preferable that the occurrence of hand eczema is reported by adolescents themselves, as they are the ones most aware of their symptoms.

Healthcare-associated infections after lower extremity revascularization.

OBJECTIVE: This population-based study aims to elucidate the incidence of healthcare-associated infections (HCAI) and related risk factors in non-emergent, open and endovascular lower extremity vascular procedures. METHOD: This was a retrospective analysis of prospectively collected data from the Swedish National Vascular Surgery registry (Swedvasc), National Patient registry, and Cause of Death registry. A nationwide survey of all postoperative infections among patients who have undergone non-emergent open and endovascular surgery for lower extremity arterial disease between January 2005 to December 2010 (n = 10,547) has been performed. Data were retrieved from the National Vascular Surgery registry and cross-matched with the National Patient and Cause of Death registries. The primary purpose of the study was to identify the rate of 30-day postoperative infections and the associated risk factors for the different classes of lower extremity ischemia and operative procedures. RESULTS: The study cohort included patients with claudication 27.0% (n = 2,827) and critical limb ischemia (CLI), consisting of rest pain 17.0% (n = 1,835) and ulceration/gangrene 56.0% (n = 5,885) undergoing endovascular intervention (n = 6,262; 59.0%), thromboendarterectomy (n = 1,061; 10.0%), or bypass surgery (n = 3,224; 31.0%). The total incidence of postoperative infection (<30-days) was 9.7% (n = 1,019), including skin and soft tissue infection (n = 735; 6.9%), urinary tract infection (n = 168; 1.6%), pneumonia (n = 114; 1.1%), and sepsis (n = 91; 0.9%). In claudicants, the risk of infection was increased eightfold for bypass surgery compared with endovascular intervention (odds ratio 8.4, 95% confidence interval 5.0-14). Risk factors associated with infection were degree of lower extremity ischemia, diabetes, renal insufficiency, and heart and lung disease (p < .05). CONCLUSION: The postoperative rate of HCAI is associated with cardiovascular risk factors, operative method, and degree of lower extremity ischemia. This may be of assistance when deciding on the type of operative procedure for these patients.

The European TREatment of severe Atopic eczema in children Taskforce (TREAT) survey.

BACKGROUND: There is a paucity of evidence for the use of systemic agents in children with atopic eczema refractory to conventional therapy, resulting in considerable variation in patient management. OBJECTIVES: The European TREatment of severe Atopic eczema in children Taskforce (TREAT) survey was established to collect data on current prescribing practice, to identify factors influencing the use of specific systemic agents, and to inform the design of a clinically relevant intervention study. METHODS: Consultant physician members of the paediatric dermatology societies and interest groups of eight European countries were invited to participate in a web-based survey. The multiple-response format questionnaire collated data on clinical practice in general, as well as detailed information on the use of systemic agents in refractory paediatric atopic eczema. RESULTS: In total, 343/765 members (44·8%) responded to the invitational emails; 89·2% were dermatologists and 71% initiate systemic immunosuppression for children with severe atopic eczema. The first-line drugs of choice were ciclosporin (43·0%), oral corticosteroids (30·7%) and azathioprine (21·7%). Ciclosporin was also the most commonly used second-line medication (33·6%), with methotrexate ranked as most popular third choice (26·2%). Around half of the respondents (53·7%) replied that they routinely test and treat reservoirs of cutaneous infection prior to starting systemic treatment. Across the eight countries, penicillins were the first-line antibiotic of choice (78·3%). CONCLUSIONS: In the absence of a clear evidence base, the European TREAT survey confirms the wide variation in prescribing practice of systemic immunosuppression in refractory paediatric atopic eczema. The results will be used to inform the design of a randomized controlled trial relevant to patient management across Europe.

Perioperative haemorrhage in endovascular abdominal aneurysm repair affects outcome.

OBJECTIVE: This study aimed to evaluate the outcome and predisposing factors related to perioperative bleeding in patients treated with endovascular aneurysm repair (EVAR) for ruptured and non-ruptured abdominal aortic aneurysm (AAA). DESIGN: This was a retrospective cohort study. METHODS: A total of 525 consecutive patients (73% elective) with AAA underwent EVAR at two vascular centres from 2008 to 2011. From registry data perioperative bleeding was analysed in relation to outcome and preoperative data. RESULTS: A total of 453 (86%) patients presented with a perioperative bleeding <1000 ml, 42 (8%) patients 1000-1999 ml, 19 (4%) patients 2000-5000 ml and 11 (2%) >5000 ml. Other than ruptured AAA (n = 90), no preoperative risk factors for increased perioperative bleeding were found. Open femoral artery access (n = 101), branched (n = 18) and uni-iliacal endografts (n = 18) and introducer size were associated with increased perioperative bleeding (P < 0.001). In multivariable logistic regression only rupture and perioperative bleeding >2000 ml were significantly related to 30-day mortality (odds ratio 10.6 (range 3.8-29.6) and 13.4 (range 4.8-37.4), respectively). Postoperative renal failure, multi-organ failure, >5 days at intensive care unit, bowel ischaemia and abdominal compartments syndrome were significantly related to perioperative bleeding >2000 ml (P < 0.001). CONCLUSION: Large perioperative bleeding during EVAR is a clinical problem that affects outcome. About 10% of elective AAA patients and 34% of patients with ruptured AAA, undergoing EVAR, present a perioperative blood loss exceeding 1 l. In our study, a perioperative blood loss exceeding 2 l was independently associated with increased mortality and morbidity in both acute and elective AAA patients. Open femoral access, branched EVAR and larger diameter introducers were associated with increased perioperative blood loss. ETHICAL APPLICATION: 2011/664-31/3 (approved).