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BACKGROUND: Approximately 25% of ambulatory surgery patients experience post-discharge nausea and vomiting (PDNV). We aimed to investigate whether palonosetron, a long-acting anti-emetic, decreases the incidence of PDNV in high-risk patients.

METHODS: In this prospective, randomised, double-blind, placebo-controlled trial, 170 male and female patients undergoing ambulatory surgery under general anaesthesia, with a high predicted risk for PDNV, were randomised to receive either palonosetron 75 μg i.v. (n=84) or normal saline (n=86) before discharge. During the first 3 postoperative days (PODs), we measured outcomes using a patient questionanaire. The primary outcome was the incidence of a complete response (no nausea, vomiting, or use of rescue medication) until POD 2. Secondary outcomes included the incidence of PDNV each day until POD 3.

RESULTS: The incidence of a complete response until POD 2 was 48% (n=32) in the palonosetron group and 36% (n=25) in the placebo group (odds ratio 1.69 [95% confidence interval: 0.85-3.37]; P=0.131). No significant difference in the incidence of PDNV was observed between the two groups on the day of surgery (47% vs 56%; P=0.31). Significant differences in the incidence of PDNV were found on POD 1 (18% vs 34%; P=0.033) and POD 2 (9% vs 27%; P=0.007). No differences were observed on POD 3 (15% vs 13%; P=0.700).

CONCLUSIONS: Compared with placebo, palonosetron did not reduce the overall incidence of PDNV up to POD 2. The lower incidence of PDNV on POD 1 and POD 2 in the palonosetron group requires further investigation.

Decisions to admit or refuse admission to intensive care for acute exacerbations of COPD (AECOPD) can be difficult, due to an uncertainty about prognosis. Few studies have evaluated outcomes after intensive care for AECOPD in patients with chronic respiratory failure requiring long-term oxygen therapy (LTOT). In this nationwide observational cohort study, we investigated survival after first-time admission for AECOPD in all patients aged ≥40 years admitted to Swedish intensive care units between January 2008 and December 2015, comparing patients with and without LTOT. Among the 4,648 patients enrolled in the study, 450 were on LTOT prior to inclusion. Respiratory support data was available for 2,631 patients; 73% of these were treated with noninvasive ventilation (NIV) only, 17% were treated with immediate invasive ventilation, and 10% were intubated after failed attempt with NIV. Compared to patients without LTOT, patients with LTOT had higher 30-day mortality (38% vs. 25%; p < 0.001) and one-year mortality (70% vs. 43%; p < 0.001). Multivariable logistic and Cox regression models adjusted for age, sex and SAPS3 score confirmed higher mortality in LTOT, odds ratio for 30-day mortality was 1.8 ([95% confidence interval] 1.5–2.3) and hazard ratio for one-year mortality was 1.8 (1.6–2.0). In summary, although need for LTOT is a negative prognostic marker for survival after AECOPD requiring intensive care, a majority of patients with LTOT survived the AECOPD and 30% were alive after one year.

Objectives: To test if impaired oxygenation or major haemodynamic instability at the time of emergency intensive care transport, from a smaller admitting hospital to a tertiary care centre, are predictors of long-term mortality.

Design: Retrospective observational study. Impaired oxygenation was defined as oxyhaemoglobin %–inspired oxygen fraction ratio (S/F ratio)<100. Major haemodynamic instability was defined as a need for treatment with norepinephrine infusion to sustain mean arterial pressure (MAP) at or above 60 mm Hg or having a mean MAP <60. Logistic regression was used to assess mortality risk with impaired oxygenation or major haemodynamic instability.

Setting: Sparsely populated Northern Sweden. A fixed-wing interhospital air ambulance system for critical care serving 900 000 inhabitants.

Participants: Intensive care cases transported in fixed-wing air ambulance from outlying hospitals to a regional tertiary care centre during 2000–2016 for adults (16 years old or older). 2142 cases were included.

Primary and secondary outcome measures: All-cause mortality at 3 months after transport was the primary outcome, and secondary outcomes were all-cause mortality at 1 and 7 days, 1, 6 and 12 months.

Results: S/F ratio <100 was associated with increased mortality risk compared with S/F>300 at all time-points, with adjusted OR 6.3 (2.5 to 15.5, p<0.001) at 3 months. Major haemodynamic instability during intensive care unit (ICU) transport was associated with increased adjusted OR of all-cause mortality at 3 months with OR 2.5 (1.8 to 3.5, p<0.001).

Conclusion: Major impairment of oxygenation and/or major haemodynamic instability at the time of ICU transport to get to urgent tertiary intervention is strongly associated with increased mortality risk at 3 months in this cohort. These findings support the conclusion that these conditions are markers for many fold increase in risk for death notable already at 3 months after transport for patients with these conditions.

Objective: We assessed the mortality risk related to the time for intensive care unit transport in a geographically large regional health care system.

Methods: Patient-level data from critical care ambulance missions were analyzed for 2,067 cases, mission time, and relevant patient factors. Mission time was used as a surrogate for the “distance” to tertiary care, and mortality at 7 days and other intervals was assessed.

Results: No increased mortality risk was found at 7 days in an unadjusted regression analysis (odds ratio = 1.00; range, 0.999-1.002; P = .66). In a secondary analysis, an increased mortality risk was observed in longer mission time subgroups and at later mortality assessment intervals (> 375 mission minutes and 90-day mortality; adjusted hazard ratio = 1.56; range, 1.07-2.28; P = .02). Negative changes in oxygenation and hemodynamic status and transport-related adverse events were associated with the longest flight times. Measurable but small changes during flight were noted for mean arterial pressure and oxygenation.

Conclusion: The main finding was that there was no overall difference in mortality risk based on mission time. We conclude that transport distances or accessibility to critical care in the tertiary care center in a geographically large but sparsely populated region is not clearly associated with mortality risk.

The aim of this study was to investigate injury incidence and patterns in female and male floorball players of different ages compared with matched controls. This study involved all floorball players in Sweden and licensed during 2010–2012, and matched controls selected from Sweden’s Total Population Register. Injury diagnoses were acquired from national health care registers. The cohort comprised 148,372 players and 614,678 controls, with the median age 13 (range, 6‒69) years. In most age groups, players were at increased risk of traumatic injury, particularly knee and eye injuries. The incidence of cruciate ligament injury increased steeply from the ages of 13 years in girls and 16 years in boys, and was more than 7 times higher in female players aged ≥ 16 years than in controls. The risk of eye injury for floorball players compared to controls was increased from the age of 10 years in male players and approximately doubled from the age of 13 years; in adult female players this risk was more than 6 times higher than in controls. Development and implementation of injury prevention measures are essential so that floorball players can safely practice their sport. Given the increased risk of injuries seen also in young players, such measures should be applied in all age categories.

Background and purpose - Metastatic spinal cord compression (MSCC) as the initial manifestation of malignancy (IMM) limits the time for diagnostic workup; most often, treatment is required before the final primary tumor diagnosis. We evaluated neurological outcome, complications, survival, and the manner of diagnosing the primary tumor in patients who were operated for MSCC as the IMM.

Patients and methods - Records of 69 consecutive patients (51 men) who underwent surgery for MSCC as the IMM were reviewed. The patients had no history of cancer when they presented with pain (n = 2) and/or neurological symptoms (n = 67).

Results - The primary tumor was identified in 59 patients. In 10 patients, no specific diagnosis could be established, and they were therefore defined as having cancer of unknown primary tumor (CUP). At the end of the study, 16 patients were still alive (median follow-up 2.5 years). The overall survival time was 20 months. Patients with CUP had the shortest survival (3.5 months) whereas patients with prostate cancer (6 years) and myeloma (5 years) had the longest survival. 20 of the 39 patients who were non-ambulatory preoperatively regained walking ability, and 29 of the 30 ambulatory patients preoperatively retained their walking ability 1 month postoperatively. 15 of the 69 patients suffered from a total of 20 complications within 1 month postoperatively.

Interpretation - Postoperative survival with MSCC as the IMM depends on the type of primary tumor. Surgery in these patients maintains and improves ambulatory function.

Background: Parkinson’s disease (PD) is a common, progressive neurodegenerative disorder, recognized by the motor symptoms of bradykinesia, tremor, rigidity, and postural impairment. At clinical onset, extensive amounts of dopaminergic neurons have already been lost. The duration of this prodromal phase is uncertain, and it is thought to include predominantly non-motor symptoms. The progressive nature and the symptoms of PD are disabling and reduces the quality of life. Among patients affected in working age, early cessation of employment is common, and such socioeconomic consequences of PD may contribute to an impaired quality of life. The aims of this thesis were to investigate the life situation for people affected by PD in working age, with attention to factors of importance for quality of life and working situation, and to evaluate long-term associations between potential prodromal signs and the later development of PD.Methods: We used a postal survey to investigate the self-perceived life situation among working-aged individuals with PD compared to matched controls, with a specific attention to socioeconomic consequences of disease (paper I). To investigate risk markers preceding the diagnosis of PD (paper II-IV), we used data from nationwide registers. Study II was performed as a cohort study, based on the Swedish Military Service Conscription Register, and study III-IV were performed as nested case-control studies based on a cohort comprising all Swedish citizens aged ≥50 years in 2005.Results: In the survey study (paper I), 38% of the PD participants and 9% of the controls were dissatisfied with life as a whole, and the working situation was an independent risk factor for dissatisfaction with life. In total, 59% of the PD participants had reduced working hours or stopped working due to PD, and many PD participants struggled to cope with their work demands. Support from employer was associated with a higher likelihood to remain employed.We found that low muscle strength in young adulthood, (paper II) and depression (paper III) were associated with an increased risk of PD over follow-up times of more than 2 decades, and that patients with PD were at increased risk of fall-related injuries, hip fractures in particular, a decade or more before the PD diagnosis (paper IV). For depression and fall-related injuries, the association with PD was clearly time-dependent, strongest in the last years before the diagnosis of PD.Conclusions: The results suggest that the prodromal phase of PD may last for more than 2 decades and include also motor symptoms. The consequences of PD include a reduced quality of life associated with the working situation. Employer’s support appear to be particularly important for a successful vocational rehabilitation.

BACKGROUND: Low muscle strength has been found in late adolescence in individuals diagnosed with Parkinson disease (PD) 30 y later. This study investigated whether this lower muscle strength also may translate into increased risks of falling and fracture before the diagnosis of PD.

METHODS AND FINDINGS: Among all Swedish citizens aged ≥50 y in 2005, two nested case-control cohorts were compiled. In cohort I, individuals diagnosed with PD during 1988-2012 (n = 24,412) were matched with up to ten controls (n = 243,363), and the risk of fall-related injuries before diagnosis of PD was evaluated. In cohort II, individuals with an injurious fall in need of emergency care during 1988-2012 (n = 622,333) were matched with one control (n = 622,333), and the risk of PD after the injurious fall was evaluated. In cohort I, 18.0% of cases and 11.5% of controls had at least one injurious fall (p < 0.001) prior to PD diagnosis in the case. Assessed by conditional logistic regression analysis adjusted for comorbid diagnoses and education level, PD was associated with increased risks of injurious fall up to 10 y before diagnosis (odds ratio [OR] 1.19, 95% CI 1.08-1.31; 7 to <10 y before diagnosis) and hip fracture ≥15 y before diagnosis (OR 1.36, 95% CI 1.10-1.69; 15-26 y before diagnosis). In cohort II, 0.7% of individuals with an injurious fall and 0.5% of controls were diagnosed with PD during follow-up (p < 0.001). The risk of PD was increased for up to 10 y after an injurious fall (OR 1.18, 95% CI 1.02-1.37; 7 to <10 y after diagnosis). An important limitation is that the diagnoses were obtained from registers and could not be clinically confirmed for the study.

CONCLUSIONS: The increased risks of falling and hip fracture prior to the diagnosis of PD may suggest the presence of clinically relevant neurodegenerative impairment many years before the diagnosis of this disease.