Management of Ocular Manifestations of Atopic Dermatitis : A Consensus Meeting Using a Modified Delphi Process

There is a need for unified guidance on the management of ocular manifestations of atopic dermatitis and ocular manifestations associated with dupilumab in the Nordic region (Denmark, Finland, Norway and Sweden). This initiative gathered Nordic dermatologists and ophthalmologists to identify consensus in this area using a modified Delphi process. The initiative was led by a Nordic expert panel who developed a questionnaire that was circulated to a wider group. The results informed an agenda consisting of 24 statements to be voted on using a 5-point Likert scale at a meeting in Copenhagen on 24 April 2019. A facilitator moderated discussion and revised statements according to expert feedback for a second vote when required to reach consensus. Consensus was reached for 23 statements regarding the diagnosis, treatment and referral of these patients, which we hope will improve patient management in the Nordic region.Peer reviewe

Interactions between neural retina,retinal epithelium and choroid

The retinal pigment epithelium (RPE) is a non-replicating monolayer that plays a key role nursing the photoreceptors of the neural retina, regulating fluid movement within the subretinal space, maintaining a basal laminar layer of Bruch s membrane, and influencing the choriocapillaris. This project investigates how surgical manipulation of the retinal epithelial layer influences the neural retina, the choroid and the epithelial layer itself. Bleb detachment is a surgical method to gain access to the subretinal space by separating the neural retina from the RPE, which can be therapeutically useful in procedures such as gene therapy and retinal cell transplantation. This method of separating the RPE from the photoreceptors is not without complications because it can produce a number of abnormalities in the RPE itself as well as in the neural retina and choroid. Jet stream pressure, the standard way to produce a bleb detachment, causes focal damage to the RPE layer and choroid and generalized damage to the apical membranes of the RPE. It also produces folds in the rabbit neural retina, which induce a gradual transformation of the RPE layer. This transformation leads to migration, proliferation and a defect in lysosomal digestion that has been associated with apoptosis. Such changes produced by bleb detachment may explain the gradual loss of RPE allografts or homografts. Photoreceptor transplants survive for a long period of time and can develop outer segments without showing evidence of apoptosis. But such photoreceptor transplants form abnormal rosettes, which may also be due to abnormalities produced in the RPE layer by bleb detachments. These problems associated with the production of bleb detachments should be considered in any attempts to introduce solutions and/or cells into the subretinal space. Attempts to reconstruct or repair the RPE layer by transplantation can involve the removal of RPE cells from Bruch s membrane before replacing them with transplanted cells; it can also involve biopsy of RPE cells for culture or transplantation to another site. The removal of RPE cells from Bruch s membrane causes significant changes in the choroid. Removal of large areas of RPE leads to inflammation and fibrosis in the choroid that compresses the large choroidal vessels leading to reduction of blood flow in the terminal choriocapillary beds. The absence of an RPE layer without its replacement may also cause atrophy of the choriocapillaris by the loss of a hypothetical trophic factor. Even slight pressure on the RPE layer without any removal of cells leads to rapid but reversible reduction in flow of large choroidal vessels, which appears to be due to vasospastic constriction and/or thrombosis. Because the recovery from such changes can take hours or days, this abnormality could lead to degeneration of the neural retina and may be related to other choroidal abnormalities. Removal of local segments of the neural retina causes profound changes in the adjacent RPE layer, which are even more pronounced than what is observed in bleb detachments or what has been described after prolonged retinal detachments. It reveals that the neural retina must inhibit the transformation of the RPE layer by releasing a factor that suppresses this response. The results are important for understanding how to enter and manipulate the structures bordering the subretinal space, the photoreceptors, the retinal epithelium and the choroid. It offers insights into how the methodology for surgical repair of these structures such as gene therapy and/or transplantation can be made more effective

Energy efficient distribution of e-grocery by transport efficient logistics and reduced car use

E-handel av dagligvaror har kommit för att stanna och är under stark utveckling. E-handeln innebär nya möjligheter med ökad tillgänglighet och service för konsumenter och samtidigt nya utmaningar för företagen som behöver anpassa sina logistiksystem för en ökad e-handel. I nuläget sker stora investeringar och det finns möjlighet att forma system som bidrar till en hållbar e-handel.Det övergripande syftet med den här rapporten är att bidra till att en energieffektiv e-handel av dagligvaror kan realiseras genom minskad energianvändning för transporter. Rapporten presenterar ny kunskap inom följande två områden: 1) Dagligvaruhandelns distributionssystem 2) Konsument-perspektiv på e-handel och inköpsresor. Metoderna som används är: litteraturstudier, intervjuer med 21 organisationer och företag inom dagligvaruhandeln, en enkätstudie med 3 000 konsumenter samt två workshops med forskare, livsmedelsproducenter, dagligvaruhandlare och logistik- och transport-aktörer. Studien är inriktad på större aktörer inom dagligvaruhandeln som erbjuder full-sortiment och matkassar samt konsumenter i medelstora och större städer.Swedish e-grocery undergoes a strong development and is becoming well-established. E-commerce gives increased accessibility and services for consumers but, at the same time, new logistics challenges for companies. At present, several companies are presenting large investments. Since the market is growing, there are possibilities to develop logistics systems that could contribute to a sustainable e-commerce. The overall purpose of this report is to contribute to energy-efficient e-grocery by decreased energy use for transport. New knowledge in the following two areas are presented: 1) Grocery distribution systems 2) Consumer perspective on e-commerce and grocery shopping trips. The methods used are literature studies, interviews with 21 organizations and companies in the grocery market, a survey with 3 000 consumers and two workshops with researchers, food producers, grocery retailers and logistics and transport players. This study focuses on major players in the grocery trade that offer full range assortment and consumers living in medium-sized and larger cities

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel : a nationwide study

AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or &gt;120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. &gt;120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.Funding agencies:  AstraZeneca; Swedish Heart and Lung Foundation [20120372, 2014021]</p

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel : a nationwide study

AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or &gt;120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. &gt;120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel : a nationwide study

AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or &gt;120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. &gt;120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.Funding agencies:  AstraZeneca; Swedish Heart and Lung Foundation [20120372, 2014021]</p

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel : a nationwide study

AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or &gt;120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. &gt;120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued &lt;24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel

Establishment and utility of SwedAD : a nationwide Swedish registry for patients with atopic dermatitis receiving systemic pharmacotherapy

SwedAD, a Swedish nationwide registry for patients with atopic dermatitis receiving systemic pharmacotherapy, was launched on 1 September 2019. We describe here the establishment of a user-friendly registry to the benefit of patients with atopic dermatitis. By 5 November 2022, 38 clinics had recorded 931 treatment episodes in 850 patients with an approximate national coverage rate of 40%. Characteristics at enrolment included median Eczema Area and Severity Index (EASI) 10.2 (interquartile range 4.0, 19.4), Patient-Oriented Eczema Measure (POEM) 18.0 (10.0, 24.0), Dermatology Life Quality Index (DLQI) 11.0 (5.0, 19.0) and Peak Itch Numerical Rating Scale-11 (NRS-11) 6.0 (3.0, 8.0). At 3 months, median EASI was 3.2 (1.0, 7.3) and POEM, DLQI, and NRS-11 were improved. Regional coverage varied, reflecting the distribution of dermatologists, the ratio of public to private healthcare, and difficulties in recruiting certain clinics. This study highlights the importance of a nationwide registry when managing systemic pharmacotherapy of atopic dermatitis