Akershus University Hospital Research Articles

Prehospital path in acute stroke.

Too few patients with acute stroke receive thrombolytic therapy owing to the limited time window for treatment and prehospital delay. The purpose of this study is to describe the prehospital path for patients with acute stroke and, in particular, what distinguishes patients who contact the Emergency Medical Communication Centre (EMCC) from those who contact their general practitioner (GP) or Out-of-hours (OOH) services. Patients with acute cerebral infarction and intracerebral haemorrhage admitted to the Stroke Unit, Department of Neurology, Akershus University Hospital, were included. Data on the prehospital path (prehospital delay, medical contacts) were collected over the period 15 April 2009 – 1 April 2010. A total of 299 patients were included in the study. The median age was 75 years and 48.5 % were women. In all, 63.9 % of patients with acute stroke called the EMCC, and 93.7 % of these were taken directly to hospital by ambulance. Of those who called the GP’s office or OOH services, 60.7 % were asked to go to the GP’s office or OOH services in person. Patients who called and attended the GP’s office or OOH services had milder neurological deficits (p < 0.001) and longer patient delay (p = 0.018) than those who called the EMCC. Six out of ten patients who contacted the primary health care services were asked to go to the GP’s office/OOH services in person, which resulted in unnecessary delay. The findings from this study may indicate a need for specific training of this group of health care professionals in the prompt handling of patients with possible stroke.

The prognostic value of measurement of high-sensitive cardiac troponin T for mortality in a cohort of stable chronic obstructive pulmonary disease patients.

BackgroundCardiovascular disease (CVD) is a common comorbidity in chronic obstructive pulmonary disease (COPD). Cardiac troponin (cTn) elevation, indicating myocardial injury, is frequent during acute COPD exacerbations and associated with increased mortality. The prognostic value of circulating cTnT among COPD patients in the stable state of the disease is still unknown.The purpose of the present study was to assess the association between circulating cTnT measured by a high sensitive assay (hs-cTnT) and all-cause mortality among patients with stable COPD without overt CVD.MethodsIn a prospective cohort study we included 275 patients from the Akershus University Hospital’s outpatient clinic and from Glittre, a pulmonary rehabilitation clinic. COPD-severity and cardiovascular risk factors were assessed, and time to all-cause death was recorded during a mean follow-up time of 2.8 years.ResultsOne hundred-eighty patients (65%) had hs-cTnT concentrations ≥ the level of detection (5.0 ng/L) and 66 patients (24%) had hs-cTnT above the normal range (≥14.0 ng/L). In total, 47 patients (17%) died. hs-cTnT concentrations in the ranges <5.0, 5.0–13.9 and ≥14 ng/L were associated with crude mortality rates of 2.8, 4.4 and 11.0 per 100 patient-years, respectively. In adjusted analyses the hazard ratios (95% confidence intervals) for death were 1.7 (0.8–3.9) and 2.9 (1.2–7.2) among patients with hs-cTnT concentrations 5.0–13.9 and ≥14 ng/L, respectively, compared to patients with hs-cTnT <5.0 ng/L.Conclusionshs-cTnT elevation is frequently present in patients with stable COPD without overt CVD, and associated with increased mortality, independently of COPD-severity and other cardiovascular risk factors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-016-0319-9) contains supplementary material, which is available to authorized users.

Chiropractic spinal manipulative therapy for migraine: a three‐armed, single‐blinded, placebo, randomized controlled trial

Background and purposeTo investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs.MethodsThis was a prospective three‐armed, single‐blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1‐month run‐in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow‐up. The primary end‐point was the number of migraine days per month, whereas secondary end‐points were migraine duration, migraine intensity and headache index, and medicine consumption.ResultsMigraine days were significantly reduced within all three groups from baseline to post‐treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow‐up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow‐up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT.ConclusionsIt is possible to conduct a manual‐therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.

The Impact of Perinatal Depression on Children's Social-Emotional Development: A Longitudinal Study.

Objectives This longitudinal population study aimed to investigate if maternal depression at different time points during the perinatal period impacts children's social-emotional development at 2years of age. Methods Participants were women (n=1235) who gave birth at Akershus University Hospital in Norway. Maternal depressive symptoms were assessed by using the Edinburgh Postnatal Depression Scale at pregnancy week 32 and at 8weeks and 2years postpartum, whereas children's social-emotional development at the age of 2years was assessed by using the Ages and Stages Questionnaire: Social-Emotional. Bi- and multivariate logistic regression analyses were conducted to examine the linkage between maternal perinatal depression and children's early social-emotional development. Results Multivariate analyses showed that social-emotional problems in the child 2years after birth were strongly associated with maternal depression at pregnancy week 32 (adjusted odds ratio (aOR) 3.4; 95% CI 1.4-8.0), depression at 8weeks postpartum (aOR 3.8; 95% CI 1.7-8.6), and with depression at both time points (aOR 3.7; 95% CI 1.5-10.1). Conclusion Findings indicate pre- and postnatal depression each bears an independent, adverse impact on children's social-emotional development.

Pediatric sleep problems and social-emotional problems. A population-based study

ObjectiveTo examine the association between sleep and social-emotional development in two-year-old toddlers. MethodsThe study is part of a longitudinal cohort study, the Akershus Birth Cohort Study, which targeted all women giving birth at Akershus University Hospital in Norway. The current study is from the fourth round of the study, including 2014 women two years after delivery. The Brief Infant Sleep Questionnaire (BISQ) and the Ages and Stages Questionnaire: Social Emotional (ASQ:SE) were filled out by the mothers and were used to assess toddler sleep, and social-emotional development, respectively. Other domains of development (communication problems, gross motor problems, and fine motor problems) were assessed with the Ages and Stages Questionnaire (ASQ). Confirmatory factor analysis was conducted on the ASQ:SE, and logistic regression analyses were used to examine both crude associations between sleep variables and social-emotional problems, and adjusting for potential confounders. ResultsThe mean sleep duration of the toddlers was 12h and 27min; the majority of the children (54%) had 1–2 awakenings per night, while 10% of the children had a sleep onset latency of more than 30min. All sleep parameters, including short sleep duration, nocturnal awakenings and sleep onset problems, were significantly associated with social-emotional problems in a dose-response manner. For example, sleeping less than 11h per night was associated with a five-fold increase in the odds of social-emotional problems, compared to sleeping 13–14h per night. Adjusting for potential confounders, including maternal age, maternal education, marital status, parity, gestational age, child birth-weight and other developmental problems, did not, or only slightly, attenuate the associations between any of the sleep variables and social-emotional problems. ConclusionsShort sleep duration, nocturnal awakenings and sleep onset problems were all associated with higher odds of social-emotional problems, even after accounting for developmental problems and demographic factors. Thus, a broad assessment of sleep and social-emotional problems when toddlers present with either can be useful.

Prospective evaluation of the cause of acute pancreatitis, with special attention to medicines.

To investigate the cause of acute pancreatitis (AP) by conducting a thorough investigation of drugs and their possible etiological role. We investigated the cause of AP in a large retrospective cohort of 613 adult patients admitted with AP at the Akershus University Hospital, Norway, from 2000 until 2009, who were evaluated with standard ward investigations. This group was compared with a prospectively evaluated group (n = 57) admitted from January 2010 until September 2010 who investigated more extensively using medical history and radiological assessment. The groups were comparable with regards to gender, age, comorbidity and severity. The most common etiology was bile stones and alcohol, occurring in 60% in both groups. The prospective group was examined more thoroughly with regards to the use of alcohol and medicines. An increased number of radiological investigations during hospital stay and at follow-up were also performed. A more extensive use of radiological evaluation did not increase the detection frequency of bile stones. In the prospective group, more than half of the patients had two or more possible causes of pancreatitis, being mostly a combination of bile stones and drugs. No possible cause was found in only 3.5% of these patients, compared with 29.7% in the retrospective group. A detailed medical history and extensive radiological evaluation may determine a possible etiology in almost all cases of AP. Many patients have several possible risk factors, and uncertainty remains in establishing the definitive etiology.

Risk adjustment in measurements of predicted mortality after myocardial infarction.

In 2014, the government introduced elements of quality-based funding (pay-for-performance) for the hospital sector. Survival is included as a quality indicator. If such quality indicators are to be used for funding purposes, it must be established that the observed variations are caused by conditions that the hospital trusts are able to influence, and not by any underlying variables. The objective of this study was to investigate how the predicted mortality after myocardial infarction was influenced by various forms of risk adjustment. Data from the Norwegian Patient Register on 10,717 patients who had been discharged with the diagnosis of myocardial infarction in 2009 were linked to data on socioeconomic status, comorbidity, travel distances and mortality. The predicted 30-day mortality after myocardial infarction was analysed at the hospital-trust level, using three different models for risk adjustment. Unadjusted 30-day mortality was highest in the catchment area of Førde Hospital Trust (12.5%) and lowest in Asker og Bærum (5.2%). Risk adjustment changed the estimates of mortality for many of the hospital trusts. In the model involving the most comprehensive risk adjustment, mortality was highest in the catchment area of Akershus University Hospital (10.9%) and lowest in the catchment areas of Sunnmøre Hospital Trust (5.2%) and Nordmøre og Romsdal Hospital Trust (5.2%). The variation in treatment quality between the hospital trusts, as measured by predicted mortality after myocardial infarction, is influenced by the methods used for risk adjustment. If the quality-based funding scheme is to continue, well-documented models for risk adjustment of the quality indicators need to be established.

An increase in the number of admitted patients with exercise-induced rhabdomyolysis.

Rhabdomyolysis may lead to serious complications, and treatment is both time-consuming and costly. The condition can be caused by many factors, including intense exercise. The purpose of this study was to investigate whether the number of hospitalisations due to exercise-induced rhabdomyolysis has changed in recent years. We describe the disease course in hospitalised patients, and compare disease course in individuals with exercise-induced rhabdomyolysis and rhabdomyolysis due to other causes. The study is a systematic review of medical records from Akershus University Hospital for the years 2008 and 2011 – 14. All hospitalised patients with diagnostic codes M62.8, M62.9 and T79.6 and creatine kinase levels > 5 000 IU/l were included. The cause of the rhabdomyolysis was recorded in addition to patient characteristics and the results of various laboratory tests. Of 161 patients who were hospitalised with rhabdomyolysis during the study period, 44 cases (27 %) were classified as exercise-induced. In 2008 there were no admissions due to exercise-induced rhabdomyolysis; in 2011 and 2012 there were six and four admissions respectively, while in 2014 there were 22. This gives an estimated incidence of 0.8/100 000 in 2012 and 4.6/100 000 in 2014. Strength-training was the cause of hospitalisation in 35 patients (80 % of the exercise-induced cases). Three patients (7 % of the exercise-induced cases) had transient stage 1 kidney injury, but there were no cases with stage 2 or stage 3 injury. By comparison, 52 % of patients with rhabdomyolysis due to another cause had kidney injury, of which 28 % was stage 2 or 3. The number of persons hospitalised with exercise-induced rhabdomyolysis has increased four-fold from 2011 to 2014, possibly due to changes in exercise habits in the population. None of the patients with exercise-induced rhabdomyolysis had serological signs of kidney injury upon hospital discharge.

Effect of postpartum pelvic floor muscle training on vaginal symptoms and sexual dysfunction-secondary analysis of a randomised trial.

Evaluate effect of pelvic floor muscle training (PFMT) on vaginal symptoms and sexual matters, dyspareunia and coital incontinence in primiparous women stratified by major or no defects of the levator ani muscle. Randomised controlled trial (RCT). Akershus University Hospital, Norway. About 175 primiparous women with a singleton vaginal delivery. Two-armed assessor blinded parallel group RCT from 6 weeks to 6 months postpartum comparing effect of PFMT versus control. International Consultation on Incontinence Modular Questionnaire-vaginal symptoms questionnaire (ICIQ-VS) and ICIQ sexual matters module (ICIQ-FLUTSsex). Overall, analysis (n = 175) showed no difference between training and control groups in women having vaginal symptoms or symptoms related to sexual dysfunction 6 months postpartum. The majority of women (88%) had intercourse and there was no difference between groups. Unadjusted subgroup analysis of women with a major defect of the levator ani muscle (n = 55) showed that women in the training group had 45% less risk of having the symptom 'vagina feels loose or lax' compared with the control group (relative risk 0.55, 95% confidence interval 0.31, 0.95; P = 0.03). Unadjusted analysis showed that in women with major defect of the levator ani muscle, significantly fewer in the training group had the symptom 'vagina feels loose or lax' compared with the control group. No difference was found between groups for symptoms related to sexual dysfunction. More studies are needed to explore effect of PFMT on vaginal symptoms and sexual dysfunction. Unadjusted analysis shows that PFMT might prevent symptoms of 'vagina feels loose or lax'.

Abstract 121: The EGFR gatekeeper mutation T790M is present in selected patients with early breast cancer

Abstract Introduction. The epidermal growth factor receptor (EGFR) is one of the major oncogenes in a variety of human cancers including breast cancer (BC). While EGFR overexpression and/or amplification has been shown to occur frequently in human breast cancer, EGFR-activating mutations are suggested to be rare if not absent. Thus, the aim of our study was to examine the presence of somatic EGFR gene mutations in a group of norwegian patients diagnosed with early breast cancer. Patients. We investigated tumor biopsies obtained from 132 patients with early breast cancer treated at the Akershus University Hospital (University of Oslo) in 2007/2008. The majority of patients (n = 82) belonged to the luminal- A/B subtypes of BC. In addition, 33 patients were classified as HER-2 positive patients (IHC 3+ or amplification verified by FISH) and 17 as triple-negative breast cancer (TNBC) patients. Methods. Briefly, DNA was extracted from formalin-fixed, paraffin-embedded (FFPE) tumor tissue using QIAsymphony DSP DNA Mini Kit (Qiagen Inc.). The extraction of DNA was performed by fully automated purification using the QIAsymphony SP/AS system. EGFR-mutations were detected using a Therascreen EGFR RGQ PCR kit according to the manufacturer´s protocol. We tested for point mutations in exon 18 (G719A/C/S), in-frame deletions in exon 19 (ΔE746-A750), in-frame insertions as well as point mutations in exon 20 (S768I, T790M) and a point mutation in exon 21 (L858R). Results. In the present study we detected three individuals with an EGFR-T790M mutation. Two of the patients were diagnosed with TNBC, while the disease of the third patient was classified as a luminal-A type breast cancer. Interestingly, the T790M-mutation was present in the biopsies obtained during surgery before adjuvant therapy was initiated. No anti-cancer therapy has been given prior to surgery. According to our best knowledge, the T790M-”TKI-resistance-mutation” has not been detected in early breast cancer previously. This finding contrasts the observations made in lung cancer patients where the T790M mutation in general is a classical second mutation causing drug resistance during ongoing TKI-therapy. No other EGFR-mutations were detected in our patients. Conclusion: To our best knowledge we provide first evidence for the presence of the EGFR-T790M-mutation in human early breast cancer. Thus, treatment with novel EGFR-targeting cancer drugs (like “pan-HER-inhibitors”) affecting also T790M-mutated-EGFR may be worthwhile to be tested in highly selected breast cancer patients. Citation Format: Vahid Bemanian, Torill Sauer, Joel Touma, Bjørn A. Lindstedt, Ying Chen, Hilde P. Ødegård, Ida R. Bukholm, Jürgen Geisler. The EGFR gatekeeper mutation T790M is present in selected patients with early breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 121. doi:10.1158/1538-7445.AM2015-121

Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study.

To describe changes in pelvic organ support from mid pregnancy until 1year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support. Prospective cohort study. Akershus University Hospital in Norway. A cohort of 300 nulliparous pregnant women included at mid-pregnancy. Pelvic organ support assessed at 21 and 37weeks of gestation, and again at 6weeks, 6months, and 12months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support. Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups. The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6weeks postpartum. At 12months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group. The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery. Pelvic organ support changes during pregnancy. A contribution to the risk of POP?

No change in the distribution of types and antibiotic resistance in clinical Staphylococcus aureus isolates from orthopaedic patients during a period of 12 years

Staphylococcus aureus (S. aureus) is the most common cause of bone and joint infections. However, limited information is available on the distribution of S. aureus geno- and phenotypes causing orthopaedic infections. The aim of this study was to identify the dominating types causing infections in orthopaedic patients, investigate if the characteristics of these types changed over time and examine if different types were more often associated with surgical site infection (SSI) than primary infection (non-SSI). All clinical S. aureus isolates collected from orthopaedic patients from 2000 through 2011 at Akershus University Hospital, Norway, were characterised by S. aureus protein A (spa) typing and tested for antibiotic resistance. A total of 548 patients with orthopaedic S. aureus infections were included, of which 326 (59 %) had SSI and 222 (41 %) had non-SSI. The median age was 62 years [range 2-97 years] and 54 % were male. Among the 242 unique spa types, t084 was the most common (7 %). Penicillin resistance was identified in 75 % of the isolates, whereas the resistances to the other antibiotics tested were <5 %. Three isolates (0.5 %) were resistant to methicillin. There was no significant difference in the distribution of geno- and phenotypes over time and there was no difference in types between SSI and non-SSI. In this large collection of S. aureus from orthopaedic patients, the S. aureus infections, regardless of origin, were heterogeneous, mainly resistant to penicillin, stable over time and consisted of similar types as previously found in both carrier and other patient populations.

Diagnostic accuracy for heart failure – data from the Akershus Cardiac Examination 2 Study

Diagnosing heart failure in an on-call setting can be difficult, and international studies report diagnostic accuracy among duty doctors, as measured using area under the ROC curve (AUC), to be 0.76-0.90. This study has examined the accuracy with which doctors in the internal medicine out-of-hours service in a Norwegian university hospital distinguish heart failure from no heart failure in patients with dyspnoea. Information was gathered on 468 patients admitted to Akershus University Hospital with dyspnoea between June 2009 and November 2010, and 314 patients were included in the study. The duty doctors estimated the probability of heart failure (0-100%) before N-terminal pro-B-type natriuretic peptide (NTproBNP) concentrations were known. The final diagnosis for the hospital admission was made retrospectively by two independent doctors after review of the medical records, including supplementary tests and the patient outcome. Heart failure was considered the cause of hospitalisation in 143 patients (46%). Patients with heart failure were older, more often men, had a higher prevalence of heart disease, reduced/impaired renal function, and higher NTproBNP concentrations than patients with non-heart failure dyspnoea. The diagnostic accuracy among duty doctors for heart failure (AUC) was 0.86 (95% confidence interval 0.82-0.90). The doctors' diagnostic accuracy was lower when the patient had heart failure with left ventricular ejection fraction [LVEF] ≥ 50% (n=52): AUC 0.83 (0.77-0.87). The duty doctors at Akershus University Hospital from 2009-2010 demonstrated similar diagnostic accuracy for heart failure as previously reported from international centres. Diagnostic accuracy was lower for heart failure patients with LVEF ≥ 50%.

Seasonally adjusted birth frequencies follow the Poisson distribution.

Variations in birth frequencies have an impact on activity planning in maternity wards. Previous studies of this phenomenon have commonly included elective births. A Danish study of spontaneous births found that birth frequencies were well modelled by a Poisson process. Somewhat unexpectedly, there were also weekly variations in the frequency of spontaneous births. Another study claimed that birth frequencies follow the Benford distribution. Our objective was to test these results. We analysed 50,017 spontaneous births at Akershus University Hospital in the period 1999-2014. To investigate the Poisson distribution of these births, we plotted their variance over a sliding average. We specified various Poisson regression models, with the number of births on a given day as the outcome variable. The explanatory variables included various combinations of years, months, days of the week and the digit sum of the date. The relationship between the variance and the average fits well with an underlying Poisson process. A Benford distribution was disproved by a goodness-of-fit test (p < 0.01). The fundamental model with year and month as explanatory variables is significantly improved (p < 0.001) by adding day of the week as an explanatory variable. Altogether 7.5% more children are born on Tuesdays than on Sundays. The digit sum of the date is non-significant as an explanatory variable (p = 0.23), nor does it increase the explained variance. INERPRETATION: Spontaneous births are well modelled by a time-dependent Poisson process when monthly and day-of-the-week variation is included. The frequency is highest in summer towards June and July, Friday and Tuesday stand out as particularly busy days, and the activity level is at its lowest during weekends.

Statin Helps Endothelial Function in COPD Subgroup

Statin Helps Endothelial Function in COPD Subgroup

Abstract CT321: Prevention of cardiac dysfunction during adjuvant breast cancer therapy: the PRADA study

Abstract Purpose: Breast cancer is the most common malignancy in women worldwide. Treatment modalities include chemotherapeutic regimens containing anthracyclines, radiotherapy, and if HER-2 positive, the monoclonal antibody trastuzumab. Anthracyclines and trastuzumab are known to cause cardiac dysfunction, which may interrupt the anticancer treatment and thus increase the risk of cancer relapse. In previous observational trials, of patients with established left ventricular dysfunction following high-dose chemotherapy, treatment with angiotensin converting enzyme inhibitors and beta-blockers appeared to be associated with beneficial effects. Experimental design: A randomized, placebo-controlled, 2x2-factorial, double-blinded study is currently conducted at Akershus University Hospital, Lørenskog, Norway. In total, 120 women receiving adjuvant breast cancer therapy including anthracyclines and, if indicated, trastuzumab and/or radiation will be enrolled. Inclusion criteria comprise age between 18-70 years, Eastern Cooperative Oncology Group performance status ≤1, serum creatinine &amp;lt;140umol/L or estimated creatinine clearance &amp;gt;60 ml/min, systolic blood pressure ≥110 and ≤170 mmHg and left ventricular ejection fraction ≥ 50%. Cardiac magnetic resonance imaging (cMRI) with gadolinium contrast, echocardiography, cardiovascular biomarkers, and electrocardiogram are used to monitor cardiac function and injury. Objective: To assess the prophylactic effect of candesartan and metoprolol monotherapy, or their combination on global left ventricular systolic function, as assessed by cMRI of the heart, during postoperative, adjuvant chemotherapy with or without anti-HER-2 treatment and/or radiotherapy for early breast cancer. Secondary objectives include assessment of cardiac function and injury by echocardiography and cardiovascular biomarkers. Status: At our institution, postoperative, adjuvant chemotherapy was considered for 261 women in the period of September 2011 through November 2013. Among these, 105 (40%) were randomized for the PRADA-study. So far, 27 of 105 (26%) women included have received trastuzumab. The inclusion is estimated to continue through March 2014. Study value: The PRADA study addresses an important clinical problem in the early breast cancer population. The study will provide novel and clinically important data concerning the potential prevention of cardiac dysfunction during adjuvant breast cancer treatment. Our first experience with repeated cardial cMRIs and echocardiography during adjuvant therapy in early breast cancer patients on cardioprotective therapy will be presented and discussed. Citation Format: Geeta Gulati, Siri Lagethon Heck, Anne Hansen Ree, Åse Bratland, Kjetil Steine, Jeanette Schulz-Menger, Berit Gravdehaug, Pavel Hoffmann, Helge Røsjø, Jürgen Geisler, Torbjørn Omland. Prevention of cardiac dysfunction during adjuvant breast cancer therapy: the PRADA study. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr CT321. doi:10.1158/1538-7445.AM2014-CT321

Personality and Perinatal Maternal Insomnia: A Study Across Childbirth

Personality may influence sleep in perinatal women. A follow-up study was conducted among 3,752 pregnant, then postpartum women at Akershus University Hospital, Norway. The Big Five personality dimensions were measured by the Mini-International Personality Item Pool in week 17 of pregnancy. Insomnia was measured by the Bergen Insomnia Scale in pregnancy week 32 and 8 weeks postpartum, along with self-reported sleep times. The Edinburgh Postnatal Depression Scale measured depression, and the Hopkins Symptom Checklist measured anxiety. Adjusted for current anxiety, depression, and demographic variables, the personality traits Neuroticism and Agreeableness were associated with insomnia in pregnancy. No personality traits were associated with postpartum insomnia. Extraversion was associated with longer postpartum sleep duration and better sleep efficiency, and Agreeableness with shorter sleep duration.

The influence of women's preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study.

BackgroundThis study aimed to examine whether a mismatch between a woman’s preferred and actual mode of delivery increases the risk of post-traumatic stress symptoms after childbirth.MethodsThe study sample consisted of 1,700 women scheduled to give birth between 2009 and 2010 at Akershus University Hospital, Norway. Questionnaire data from pregnancy weeks 17 and 32 and from 8 weeks postpartum were used along with data obtained from hospital birth records. Post-traumatic stress symptoms were measured with the Impact of Event Scale. Based on the women’s preferred and actual mode of delivery, four groups were established: Match 1 (no preference for cesarean section, no elective cesarean section, N = 1,493); Match 2 (preference for cesarean section, elective cesarean section, N = 53); Mismatch 1 (no preference for cesarean section, elective cesarean section, N = 42); and Mismatch 2 (preference for cesarean section, no elective cesarean section, N = 112). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were conducted to examine whether the level of post-traumatic stress symptoms differed significantly among these four groups.ResultsExamining differences for all four groups, ANOVA yielded significant overall group differences (F = 11.96, p < 0.001). However, Bonferroni post-hoc tests found significantly higher levels of post-traumatic stress symptoms only in Mismatch 2 compared to Match 1. This difference could be partly explained by a number of risk factors, particularly psychological risk factors such as fear of childbirth, depression, and anxiety.ConclusionsThe results suggest increased post-traumatic stress symptoms in women who preferred delivery by cesarean section but delivered vaginally compared to women who both preferred vaginal delivery and delivered vaginally. In psychologically vulnerable women, such mismatch may threaten their physical integrity and, in turn, result in post-traumatic stress symptoms. These women, who often fear childbirth, may prefer a cesarean section even though vaginal delivery is usually the best option in the absence of medical indications. To avoid potential trauma, fear of childbirth and maternal requests for a cesarean section should be taken seriously and responded to adequately.

Can insomnia in pregnancy predict postpartum depression? A longitudinal, population-based study.

BackgroundInsomnia and depression are strongly interrelated. This study aimed to describe changes in sleep across childbirth, and to evaluate whether insomnia in pregnancy is a predictor of postpartum depression.MethodsA longitudinal, population-based study was conducted among perinatal women giving birth at Akershus University Hospital, Norway. Women received questionnaires in weeks 17 and 32 of pregnancy and eight weeks postpartum. This paper presents data from 2,088 of 4,662 women with complete data for insomnia and depression in week 32 of pregnancy and eight weeks postpartum. Sleep times, wake-up times and average sleep durations were self-reported. The Bergen Insomnia Scale (BIS) was used to measure insomnia. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms.ResultsAfter delivery, sleep duration was reduced by 49 minutes (to 6.5 hours), and mean sleep efficiency was reduced from 84% to 75%. However, self-reported insomnia scores (BIS) improved from 17.2 to 15.4, and the reported prevalence of insomnia decreased from 61.6% to 53.8%. High EPDS scores and anxiety in pregnancy, fear of delivery, previous depression, primiparity, and higher educational level were risk factors for both postpartum insomnia and depression. Insomnia did not predict postpartum depression in women with no prior history of depression, whereas women who recovered from depression had residual insomnia.LimitationsDepression and insomnia were not verified by clinical interviews. Women with depressive symptoms were less likely to remain in the study.ConclusionsAlthough women slept fewer hours at night after delivery compared to during late pregnancy, and reported more nights with nighttime awakenings, their self-reported insomnia scores improved, and the prevalence of insomnia according to the DSM-IV criteria decreased. Insomnia in pregnancy may be a marker for postpartum recurrence of depression among women with previous depression.

The Role of Labor Pain and Overall Birth Experience in the Development of Posttraumatic Stress Symptoms: A Longitudinal Cohort Study

The aim of this prospective study was to investigate the role of labor pain and overall birth experience in the development of posttraumatic stress symptoms in a comprehensive framework. The study sample (N = 1893) comprised women with a vaginal delivery and was drawn from the Akershus Birth Cohort, which targeted all women scheduled to give birth at Akershus University Hospital in Norway. Questionnaires were given at three different stages: from pregnancy weeks 17 to 32, from the maternity ward, and from 8 weeks postpartum. Data were also obtained from the hospital's birth record. Using structural equation modeling, a prospective mediation model was tested. Posttraumatic stress symptoms were significantly related to both labor pain (r = 0.23) and overall birth experience (r = 0.39). A substantial portion (33%) of the effect of labor pain on posttraumatic stress symptoms was mediated by the overall birth experience. Although the results of this study showed that both labor pain and overall birth experience played a role in the development of posttraumatic stress symptoms after childbirth, overall birth experience appeared to be the central factor. The women's birth experience was not only related to posttraumatic stress symptoms directly but also mediated a substantial portion of the effect of labor pain on posttraumatic stress symptoms. Future work should address which areas of birth experience confer protective effects on women to improve clinical care.