Plasma-Metanephrines in Patients with Autoimmune Addison’s Disease with and without Residual Adrenocortical Function

Purpose: Residual adrenocortical function, RAF, has recently been demonstrated in one-third of patients with autoimmune Addison’s disease (AAD). Here, we set out to explore any influence of RAF on the levels of plasma metanephrines and any changes following stimulation with cosyntropin. Methods: We included 50 patients with verified RAF and 20 patients without RAF who served as controls upon cosyntropin stimulation testing. The patients had abstained from glucocorticoid and fludrocortisone replacement > 18 and 24 h, respectively, prior to morning blood sampling. The samples were obtained before and 30 and 60 min after cosyntropin stimulation and analyzed for serum cortisol, plasma metanephrine (MN), and normetanephrine (NMN) by liquid-chromatography tandem-mass pectrometry (LC-MS/MS). Results: Among the 70 patients with AAD, MN was detectable in 33%, 25%, and 26% at baseline, 30 min, and 60 min after cosyntropin stimulation, respectively. Patients with RAF were more likely to have detectable MN at baseline (p = 0.035) and at the time of 60 min (p = 0.048) compared to patients without RAF. There was a positive correlation between detectable MN and the level of cortisol at all time points (p = 0.02, p = 0.04, p < 0.001). No difference was noted for NMN levels, which remained within the normal reference ranges. Conclusion: Even very small amounts of endogenous cortisol production affect MN levels in patients with AAD

Residual Corticosteroid Production in Autoimmune Addison Disease

Context - Contrary to current dogma, growing evidence suggests that some patients with autoimmune Addison disease (AAD) produce corticosteroids even years after diagnosis. Objective - To determine frequencies and clinical features of residual corticosteroid production in patients with AAD. Design - Two-staged, cross-sectional clinical study in 17 centers (Norway, Sweden, and Germany). Residual glucocorticoid (GC) production was defined as quantifiable serum cortisol and 11-deoxycortisol and residual mineralocorticoid (MC) production as quantifiable serum aldosterone and corticosterone after > 18 hours of medication fasting. Corticosteroids were analyzed by liquid chromatography–tandem mass spectrometry. Clinical variables included frequency of adrenal crises and quality of life. Peak cortisol response was evaluated by a standard 250 µg cosyntropin test. Results - Fifty-eight (30.2%) of 192 patients had residual GC production, more common in men (n = 33; P P P P P P P  Conclusion - In established AAD, one-third of the patients still produce GCs even decades after diagnosis. Residual production is more common in men and in patients with shorter disease duration but is not associated with adrenal crises or quality of life

Altered biomarkers for cardiovascular disease and inflammation in autoimmune Addison's disease - a cross-sectional study

Objective - Increased prevalence of cardiovascular disease has been reported in autoimmune Addison's disease (AAD), but pathomechanisms are poorly understood. Methods - We compared serum levels of 177 cardiovascular and inflammatory biomarkers in 43 patients with AAD at >18-h glucocorticoid withdrawal and 43 matched controls, overall and stratified for sex. Biomarker levels were correlated with the frequency of adrenal crises and quality of life (QoL) by AddiQoL-30. Finally, we investigated changes in biomarker levels following 250 µg tetracosactide injection in patients without residual adrenocortical function (RAF) to explore glucocorticoid-independent effects of high ACTH. Results - Nineteen biomarkers significantly differed between patients with AAD and controls; all but 1 (ST1A1) were higher in AAD. Eight biomarkers were significantly higher in female patients compared with controls (IL6, MCP1, GAL9, SPON2, DR4, RAGE, TNFRSF9, and PGF), but none differed between male patients and controls. Levels of RAGE correlated with the frequency of adrenal crises (r = 0.415, P = .006) and AddiQoL-30 scores (r = −0.347, P = .028) but not after correction for multiple testing. PDL2 and leptin significantly declined 60 min after injection of ACTH in AAD without RAF (−0.15 normalized protein expression [NPX], P = .0001, and −0.25 NPX, P = .0003, respectively). Conclusions - We show that cardiovascular and inflammatory biomarkers are altered in AAD compared with controls, particularly in women. RAGE might be a marker of disease severity in AAD, associated with more adrenal crises and reduced QoL. High ACTH reduced PDL2 and leptin levels in a glucocorticoid-independent manner but the overall effect on biomarker profiles was small

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Relationally focused specialized foster care : Relational experiences and changes in mental health and adaptive functioning

Background: Foster care is a relatively common arrangement when parents are unable to meet the needs of their children. Specialized foster care is sometimes applied in cases when problems are more serious and complex. More knowledge is needed about the effects of such specialized foster care. Aims: To explore trajectories of change associated with specialized foster care in a treatment model with a relational and mentalization-based orientation, and to develop the understanding of foster children’s and their foster parents’ experiences of their relationship living in a treatment foster family. Methods: Children and young people between the ages of 5 and 20 years who received treatment within a specialized foster care model, Treatment By Foster care (TBF), participated in this study. Longitudinal data collected in a naturalistic setting were analyzed quantitatively. In Studies 1 and 2, the number of participants at baseline varied for different instruments between 76 – 105. The Achenbach System of Empirically Based Assessment (ASEBA) was used to measure how psychiatric symptoms change from the perspectives of the foster children, the foster parents, and teachers. The Adaptive Behavior Assessment System – second edition (ABAS-II) was used to measure adaptive functioning from the foster parents’ perspective. Self-ratings by the children and young people of their emotional and social problems were measured with the Beck Youth Inventories of Emotional and Social Impairment (BYI). Data about experiences of the relationship between child and foster parent were collected through repeated individual short interviews/speeches with both children and their foster parents according to Five Minute Speech Sample (FMSS) (n = 14). Interviews/speeches were analyzed using Thematic Analysis (TA). Results: The ratings of foster parents and foster children differed. The analyses showed a significant reduction in psychiatric symptoms, emotional and social problems according to the self-ratings by the children and young people. According to foster parents and teachers, psychiatric symptoms did not decrease. The baseline ratings of adaptive functioning by foster parents showed that adaptive functioning was considerably below peers from the Swedish non-clinical norm group. Adaptive functioning did improve but not enough to approach or catch up with peers. Analysis of the interviews/speeches generated three main themes containing seven subthemes. Main themes were: No 'real' family, A co-created relationship, and Time. Participants related to a norm for what a 'real' family is and seemed to presuppose that the biological family is the 'real' family. A co-created relationship related to No 'real' family as an answer or a solution. The challenges in the foster family constellation could be overcome by a mutual ambition to build a relationship and by liking each other. Time appeared as a common theme and both as an opportunity and a threat to the relationship. Despite the fact that no interview question concerned the duration of the relationship, the participants described their relationship based on how long they had known each other. Conclusions: According to the foster children’s and young people’s self-ratings, their mental health improved, and their social problems decreased. It is likely that the TBF-model contributed to this improved psychological well-being, although causal relationships could not be established without any comparison group. However, the model did not seem to contribute to the foster parents experiencing improvement in the foster children’s psychological well-being or adaptive functioning. Based on the results of this thesis, it may be effective to place children and young people in specialized foster care with a relational and mentalization-oriented focus, but the results are not clear-cut. Practice and policies should take greater account of the time aspect in foster care, and work with the aim of increasing clarity and security, and thereby enabling a more stable upbringing for some of society’s most vulnerable children. Also, this may make foster parents want to continue their mission. More studies are needed to gain knowledge about how specialized foster care should be applied. Future studies also need to focus on creating knowledge about which aspects of the treatment are decisive.Familjehemsplacering är en förhållandevis vanlig åtgärd när föräldrar inte kan tillgodose sina barns behov. Specialiserad, mycket förstärkt, familjehemsvård används ibland i de fall då problemen är mer allvarliga och komplexa. Det behövs mer kunskap om effekterna av sådana insatser. Syftet med denna avhandling har varit att utforska förändringsbanor förknippade med mycket förstärkt familjehemsvård i en relationsinriktad och mentaliseringsbaserad behandlingsmodell, och att utveckla förståelsen för familjehemsplacerade barns och deras familjehemföräldrars upplevelser av sin relation i en behandlingsfamilj. Barn och unga i åldrarna mellan 5 till 20 år som fått behandling inom en mycket förstärkt familjehemsmodell, Treatment By Foster care (TBF), deltog i denna studie. Longitudinella data som samlats in i en naturalistisk miljö analyserades kvantitativt. I studierna 1 och 2 varierade antalet deltagare vid baseline för olika instrument mellan 76 – 105. Achenbach System of Empirically Based Assessment (ASEBA) användes för att mäta hur psykiatriska symtom förändras ur de familjehemsplacerade barnens, familjehemsföräldrarnas och lärarnas perspektiv. Adaptive Behaviour Assessment System – second edition (ABAS-II) användes för att mäta adaptiva färdigheter ur familjehemsföräldrarnas perspektiv. Barnen och ungdomarna skattade sina emotionella och sociala problem med Beck Youth Inventories of Emotional and Social Impairment (BYI). Data om upplevelser av relationen mellan familjehemsplacerade barn och familjehemsföräldrar samlades in genom upprepade individuella korta intervjuer/tal med både barn och deras familjehemsföräldrar enligt Five Minute Speech Sample (FMSS) (n = 14). Intervjuer/tal analyserades med tematisk analys (TA). Resultaten visade att barnens och familjehemsföräldrarnas skattningar skilde sig åt. Analyserna visade en signifikant minskning av psykiatriska symtom, känslomässiga och sociala problem enligt barnens och ungdomarnas självskattningar. Enligt familjehemsföräldrar och lärare minskade inte de psykiatriska symtomen. Skattningar vid baseline av adaptiva färdigheter visade att de skattade adaptiva färdigheter betydligt lägre än för jämnåriga från den svenska icke-kliniska normgruppen. Adaptiva färdigheter förbättrades men inte tillräckligt för att närma sig eller komma ikapp jämnåriga. Analysen av intervjuerna/talen genererade tre huvudteman innehållande sju underteman. Huvudteman var: Ingen 'riktig' familj, En samskapad relation och Tid. Deltagarna relaterade till en norm för vad en 'riktig' familj är och verkade förutsätta att den biologiska familjen är den 'riktiga' familjen. En samskapad relation relaterade som ett svar eller en lösning till Ingen 'riktig' familj. Utmaningarna i familjehemskonstellationen kunde övervinnas genom en ömsesidig ambition att bygga en relation och genom att man tycker om varandra. Tid framstod som ett återkommande tema och både som en möjlighet och ett hot mot relationen. Trots att ingen intervjufråga gällde relationens varaktighet beskrev deltagarna sin relation utifrån hur länge de känt varandra. Sammanfattningsvis förbättrades barnens och ungdomarnas psykiska hälsa och deras sociala problem minskade enligt deras självskattningar. Det är troligt att TBF-modellen bidrog till deras förbättrade psykologiska välbefinnande, även om orsakssamband inte kunde fastställas utan någon jämförelsegrupp. Modellen verkade inte bidra till att familjehemsföräldrarna upplevde att barnen förbättrades vad gäller psykiskt välbefinnande eller adaptiva färdigheter. Utifrån resultaten av denna avhandling kan det vara verkningsfullt att placera barn och ungdomar i mycket förstärkt familjehemsvård med en relations- och mentaliseringsbaserad inriktning, men resultaten är inte entydiga. Praxis och policier bör ta större hänsyn till tidsaspekten vid familjehemsplaceringar och arbeta för att öka tydlighet och trygghet, och därigenom möjliggöra en stabilare uppväxt för några av samhällets mest utsatta barn. Detta kan också få familjehemsföräldrar att vilja fortsätta sitt uppdrag. Fler studier behövs för att få kunskap om hur insatser och behandling i familjehemsvård bör tillämpas. Framtida studier behöver också fokusera på att skapa kunskap om vilka aspekter av behandlingen som är avgörande

Think H2O! – An educational partnership to raise students’ awareness of the water challenges

Think H2O! – An educational partnership to raise students’ awareness of the water challenges Introduction: To secure future access to safe water is one of the most important sustainability challenges, on local and global level. Water is a cause of conflict and cooperation in an increasingly complex world. This crucial challenge requires a transdisciplinary approach (Segalàs & Tejedor, 2013) and extensive educational efforts and continuous engagement of many different stakeholders and actors. Sydvatten AB and Lund University Centre for Sustainability Studies (LUCSUS) cooperate in several educational projects Sydvatten is a non-profit, municipality-owned company that produces drinking water for 900,000 residents in the south of Sweden and has a long-term responsibility to ensure future supply of drinking water for this region. LUCSUS is a university platform for education, research and cooperation inside and outside academia on questions related to sustainable development. Objectives: This paper gives an example of how different stakeholders and actors can work together in educational projects to highlight the value of water and to increase young people’s awareness, knowledge and understanding of water issues. More specifically the project aims to demonstrate the wide range of topics within water challenges and to encourage students to further education or engagement to promote sustainable development within the water sector. Methods: In the long-term project Think H2 O! Sydvatten offers teachers and their students in upper secondary school, a scholarship for a two-day watercourse at lake Bolmen, which is one of the most important resources for drinking water in Sweden. The course activities are a mix of workshops, lectures, role-play, experiments, canoeing, camping and outdoor cooking. The teachers and facilitators are from LUCSUS, Sydvatten, Vildmarksgymnasiet (the local Wilderness school) and the local business Tiraholms Fisk. The many partners involved give the students access to different competencies, skills and experiences. Master students at Lund University have developed some of the teaching material. Results: This collaboration emphasizes the transdisciplinary aspects of water, which increase the pedagogical value. The results are based on three pilot groups during 2014, with totally 150 students. The students’ evaluations demonstrate increased awareness of the value of water and a deeper understanding of the complexity of water challenges. Conclusion: The promising results show the great potential of the project and during 2015 another 500 students will be invited to participate. Despite the difficulties to evaluate the lasting effects, it is the intention of Sydvatten, the funder, to expand the project to a long-term investment. Due to demanding future sustainability challenges, it is Sydvatten’s and LUCSUS’ responsibility, as community stakeholders, to promote greater public awareness of the value of water. The project Think H2 O! is an example of social responsibility of actors in the public sector. Keywords: education, partnership, water challenges, value of wate

Effects of Mentalization-based Interventions on Mental Health of Youths in Foster Care

Knowledge about the development of mental health in young people in foster care is limited. This naturalistic study examined the effects of a relational and mentalization-focused treatment in foster families in Sweden on the placed young people’s mental health. The Achenbach System of Empirically Based Assessment (ASEBA) was used to measure change in psychiatric symptoms. Self-ratings showed significant improvements and medium to strong effects after 24 months in both boys and girls. No significant changes were found in the foster parents’ ratings or in the school staff’s ratings. Foster parents’ ratings suggested that girls’ behavioral problems decreased, but not the boys’. Based on these findings, we want to emphasize the importance of evaluating treatment effects using self-ratings by the young people in addition to parents’ and parent substitutes’ ratings

0253 Hairdressers are occupationally exposed to ortho- and meta- toluidine

Hairdressing work is classified as carcinogenic based on excess risk for bladder cancer. We aimed at evaluating if current hairdressers are exposed to established/suspected bladder carcinogens (aromatic amines) and indicate possible sources of exposure