Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice

Background

European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known.

Aim

The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs).

Methods

A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023.

Results

Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36–37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72–96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available.

Conclusion

Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.     

Anthropometric and reproductive factors and risk of esophageal and gastric cancer by subtype and subsite: Results from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort

Obesity has been associated with upper gastrointestinal cancers; however, there are limited prospective data on associations by subtype/subsite. Obesity can impact hormonal factors, which have been hypothesized to play a role in these cancers. We investigated anthropometric and reproductive factors in relation to esophageal and gastric cancer by subtype and subsite for 476,160 participants from the European Prospective Investigation into Cancer and Nutrition cohort. Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox models. During a mean follow-up of 14 years, 220 esophageal adenocarcinomas (EA), 195 esophageal squamous cell carcinomas, 243 gastric cardia (GC) and 373 gastric noncardia (GNC) cancers were diagnosed. Body mass index (BMI) was associated with EA in men (BMI ≥30 vs. 18.5–25 kg/m²: HR = 1.94, 95% CI: 1.25–3.03) and women (HR = 2.66, 95% CI: 1.15–6.19); however, adjustment for waist-to-hip ratio (WHR) attenuated these associations. After mutual adjustment for BMI and HC, respectively, WHR and waist circumference (WC) were associated with EA in men (HR = 3.47, 95% CI: 1.99–6.06 for WHR >0.96 vs. <0.91; HR = 2.67, 95% CI: 1.52–4.72 for WC >98 vs. <90 cm) and women (HR = 4.40, 95% CI: 1.35–14.33 for WHR >0.82 vs. <0.76; HR = 5.67, 95% CI: 1.76–18.26 for WC >84 vs. <74 cm). WHR was also positively associated with GC in women, and WC was positively associated with GC in men. Inverse associations were observed between parity and EA (HR = 0.38, 95% CI: 0.14–0.99; >2 vs. 0) and age at first pregnancy and GNC (HR = 0.54, 95% CI: 0.32–0.91; >26 vs. <22 years); whereas bilateral ovariectomy was positively associated with GNC (HR = 1.87, 95% CI: 1.04–3.36). These findings support a role for hormonal pathways in upper gastrointestinal cancers.     

Dental plaque, gingival inflammation, and elevated levels of interleukin-6 and cortisol in gingival crevicular fluid from women with stress-related depression and exhaustion

BACKGROUND: The aim of the present study was to investigate the importance of stress for the development of periodontitis by comparing oral health status, proinflammatory markers, and cortisol in gingival crevicular fluid (GCF) and saliva in patients with stress-related mental depression and controls. METHODS: The participants consisted of 43 women with stress-related depression and exhaustion (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV], with a mean age of 42.0 (+/- 9.3 SD) years, and 29 controls, with a mean age of 54.5 (+/- 2.9 SD) years. Clinical examination included the assessment of dental plaque, gingival inflammation (GI), bleeding on probing (BOP), probing depth (PD), clinical attachment level (CAL), and number of teeth. GCF was collected with an intracrevicular washing technique from four sites in each subject. Interleukin (IL)-1beta, IL-6, and matrix metalloproteinase-9 were determined with enzyme-linked immunosorbent assay and cortisol with radioimmunoassay (125I RIA). Analysis of covariance (one-way covariance analyses) was used to remove the influence of age and smoking. RESULTS: The amount of plaque was significantly higher in patients compared to controls (P<0.003). The patients had an average GI of 1.53 (+/-0.13 SD) compared to 0.89 (+/- 0.10 SD) for the controls (P< 0.001). The levels of cortisol in GCF was significantly higher in patients than in controls, 3.46 nmol/l (+/- 3.25 SD) and 0.30 nmol/l (+/- 0.25 SD), respectively (P<0.001), whereas cortisol in saliva did not differ between groups. The levels of IL-6 in GCF were significantly higher in the patients than in controls (P<0.05). CONCLUSION: Women with stress-related depression and exhaustion had more plaque accumulation, GI and increased levels of IL-6 and cortisol in GCF compared to normal controls, suggesting that depression might affect immune function, which could lead to impaired periodontal health.     

New attachment following surgical treatment of human periodontal disease

Abstract The present experiment was undertaken to test the hypothesis that new connective tissue attachment may form on a previously periodontitis involved root surface provided cells originating from the periodontal ligament are enabled to repopulate the root surface during healing. A mandibular incisor with advanced periodontal disease of long standing (the distance between the cemento-enamel junction and the alveolar bone crest was 9 mm) was subjected to periodontal surgery using a technique which during healing prevented the dentogingival epithelium and the gingival connective tissue from reaching contact with the curetted root surface. Preference was hereby given to the periodontal ligament cells to repopulate the previously diseased root surface. After 3 months of healing a block biopsy containing the incisor and surrounding tissue was sampled. The histological analysis revealed that new cementum with inserting principal fibers had formed on the previously diseased root surface. This new attachment extended in coronal direction to a level 5 mm coronal to the alveolar bone crest. This finding suggests that new attachment can be achieved by cells originating from the periodontal ligament and demonstrates that the concept that the periodontitis affected root surface is a major preventive factor for new attachment is invalid.     

Influence of experimental neutropenia in dogs with chronic gingivitis

The influence of a four day period of experimental neutropenia on the clinical state and the structural constituents of chronically inflamed gingiva has been studied in four beagle dogs. Neutropenia was induced by heterologous anti-neutrophil serum. The effects on the gingiva were evaluated by Gingival Index (GI) and Gingival Exudate measurements and by morphometric analysis of various tissue components in sections from biopsies of buccal gingiva sampled on days 2, 3, and 4. Control biopsies were obtained before induction of neutropenia. The GI did not markedly change during the observation period. The amount of Gingival Exudate, however, significantly decreased following the induction of neutropenia and remained low throughout the experiment. Neutrophilic granulocytes disappeared in the gingival tissues, while, apart from a relative increase in plasma cells, no other tissue components seemed to change. No bacterial invasion of the junctional epithelium or of the gingival connective tissue could be observed. Thus during a four day period the bacterial defense mechanisms at the dentogingival junction seem to be able to prevent penetration of microorganisms into the gingival tissues despite the absence of neutrophilic granulocytes.     

Progressively increasing fracture risk with advancing age after initial incident fragility fracture: The Tromsø Study

The risk of subsequent fracture is increased after initial fractures; however, proper understanding of its magnitude is lacking. This population‐based study examines the subsequent fracture risk in women and men by age and type of initial incident fracture. All incident nonvertebral fractures between 1994 and 2009 were registered in 27,158 participants in the Tromsø Study, Norway. The analysis included 3108 subjects with an initial incident fracture after the age of 49 years. Subsequent fracture (n = 664) risk was expressed as rate ratios (RR) and absolute proportions irrespective of death. The rates of both initial and subsequent fractures increased with age, the latter with the steepest curve. Compared with initial incident fracture rate of 30.8 per 1000 in women and 12.9 per 1000 in men, the overall age‐adjusted RR of subsequent fracture was 1.3 (95% CI, 1.2–1.5) in women, and 2.0 (95% CI, 1.6–2.4) in men. Although the RRs decreased with age, the absolute proportions of those with initial fracture who suffered a subsequent fracture increased with age; from 9% to 30% in women and from 10% to 26% in men, between the age groups 50–59 to 80+ years. The type of subsequent fracture varied by age from mostly minor fractures in the youngest to hip or other major fractures in the oldest age groups, irrespective of type and severity of initial fracture. In women and men, 45% and 38% of the subsequent hip or other major fractures, respectively, were preceded by initial minor fractures. The risk of subsequent fracture is high in all age groups. At older age, severe subsequent fracture types follow both clinically severe and minor initial incident fractures. Any fragility fracture in the elderly reflects the need for specific osteoporosis management to reduce further fracture risk. © 2013 American Society for Bone and Mineral Research.     

Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care

Objective This prospective observational study was designed to explore the relationships between post-traumatic stress disorder (PTSD), patients' memories of the intensive care unit (ICU) and sedation practices. Design Prospective multi-centre follow-up study out to 3 months after ICU discharge. Setting Two district general hospitals and three teaching hospitals across Europe. Patients and participants Two hundred and thirty-eight recovering, post-ventilated ICU patients. Interventions None. Measurements and results Assessment of patients' memories of ICU was undertaken at 1–2 weeks post ICU discharge. Patients' psychological recovery was assessed by examining the level of PTSD-related symptoms and rate of PTSD by 3 months post ICU. The rate of defined PTSD was 9.2%, ranging from 3.2% to 14.8% in the different study ICUs. Independent of case mix and illness severity, the factors found to be related to the development of PTSD were recall of delusional memories, prolonged sedation, and physical restraint with no sedation. Conclusion The development of PTSD following critical illness is associated with a number of different precipitating factors that are in part related to how patients are cared for within intensive care. This study raises the hypothesis that the impact of care within the ICU has an impact on subsequent psychological morbidity and therefore must be assessed in future studies looking at the way patients are sedated in the ICU and how physical restraint is used.     

Cationic Polymerization of (3‐Aminopropyl)‐tris‐furfuryloxysilane Derivatives—a New Strategy for Complex Hybrid Material Synthesis

The trifunctional (3‐aminopropyl)‐tris‐furfuryloxysilane monomer ( 1 ) is able to undergo both twin polymerization and reaction with electrophilic compounds such as isocyanates. 1 can be readily synthesized from 3‐aminopropyptrimethoxysilane (APTMS) and furfuryl alcohol (FA). The reaction of 1 with three different aromatic isocyanates, namely phenyl isocyanate, diphenylmethane‐4,4′‐diisocyanate (MDI), and a prepolymer consisting of MDI end‐capped polytetramethylene ether glycole (PTMEG), to the corresponding substituted urea derivatives is presented. Three urea derivatives 1‐phenyl‐3‐(3‐tris‐furfuryloxysilyl)propylurea ( 2 ), diphenylmethan‐4,4′‐bis[3(tris‐furfuryloxysilyl)propyl]urea ( 3 ), bis[3(tris‐furfuryloxysilyl)‐propyl]urea‐capped PTMEG‐MDI‐prepolymer ( 4 ) as well as 1 were polymerized to multicomponent organic/inorganic hybrid materials in a one step procedure using methane sulfonic acid as catalyst. The simultaneous formations of poly furfuryl alcohol and polysiloxane networks within the hybrid material are proven by means of solid‐state NMR spectroscopic measurements. The homogeneous distribution of silicon within the solidified hybrid materials is analyzed by scanning electron microscopy, energy dispersive X‐ray spectroscopy, and high‐angle annular dark field‐scanning transmission electron microscopy (HAADF)‐STEM. Homogeneous nanostructured hybrid materials with silicon cluster sizes in the range of 2 nm have been obtained by polymerization of the urea derivatives 2 , 3, and 4 .