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The Swedish Extended Producer Responsibility stipulates recycling rates but does not address the quality of the recycling. This gives an incentive for downcycling, which affects what primary material can be substituted by recycled plastics. To shed light on the climate aspects of high-quality plastics recycling, we compare the climate impacts of (1) no recycling, (2) downcycling and (3) advanced sorting that allows for substantial high-quality mechanical recycling. We discuss the limitations of common approaches to modelling recycling; we then select a basket-of-functions approach with a broad systems perspective. In our model, each tonne of high-quality recyclate replaces 900 kg primary plastics in a closed loop. Downcycled plastics instead compete with wood in railway sleepers that are incinerated with energy recovery at the end of their service life. The model accounts for impacts of recycling and downcycling on both near-term and future Swedish waste incineration, the waste imports, and the waste management and energy systems in the rest of Europe. The basket of functions generated by the system model includes packaging, supply of railway sleepers, treatment of near-term and future European waste, near-term and future European gas supply, and future electricity supply. Our results include no avoided burdens but only the emissions associated with generating the many functions of the system. They indicate that downcycling is better for the climate than no recycling, mainly because the incineration of downcycled material is postponed until after the end of the second use. This allows for a greater near-term import of waste that, in turn, reduces landfill disposal of mixed waste in other countries. The case with advanced sorting has the lowest climate impact because it involves the least primary production of polymers and the least total incineration of waste plastics. Common approaches to model recycling fail to account for key aspects in the assessment. The basket-of-functions approach allows for assessing complex impacts of recycling in a broad systems perspective, although it requires multiple assumptions to be made in the model. High-quality recycling increases the chance that the recycled plastics replace primary plastics. This leads to a greater climate benefit. The basket-of-functions approach should be considered when a decision on a material flow has complex foreseeable system impacts. A plastics-recycling policy generates greater climate benefits if it gives incentives for high-quality recycling.

There is a collective call from the field of suicide research for studies on the individual dynamics of suicidality in order to understand the deadliness of the suicidal process. This study examines the deceased next of kin's ('survivor's) experience of the suicidal process in order to gain perspectives that can be used in the preventive care of suicidal patients. The aim of this study was to explore the suicide process through the suicide survivor's experience. The study is designed and conducted through a phenomenological, reflective lifeworld approach. Twelve in-depth interviews concerning lived experiences of a suicide were conducted. The suicide process is described as the emerging of an obscured transformation of self, and an aligning to this changing understanding of self that forms a unique suicidal death course. This death course contains the co-occurrence of life and death orientations. Survivors' collected knowledge of a suicidal trajectory helps us understand the life conditions of a suicidal person that has ended their life. Life orientation and experiences of self-governance are critical parts of a suicidal trajectory and can have great preventive potential for care and assessments during suicidality. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were used for the reporting structure of this article.

Simple SummaryAlthough animals are being employed for a growing number of roles to support people, the terms used to describe those animals (e.g., “therapy animal” and “emotional support animal”) can be confusing. The same term may be used to describe different types of work, or the same role can be described with different terms. This paper presents the results of a collaboration between over 100 researchers, practitioners, and end users of animal-based supports from all over the world. We created working definitions for the following nine terms: “assistance animal”, “companion animal”, “educational/school support animal”, “emotional support animal”, “facility animal”, “service animal”, “skilled companion animal”, “therapy animal”, and “visiting/visitation animal”. In this paper, we describe the defining characteristics of each animal type and how it is different from the other types. We recommend phasing out the terms “skilled companion animal” and “service animal”, because they are similar to other terms. We discuss how our definitions may be received in different parts of the world.The nomenclature used to describe animals working in roles supporting people can be confusing. The same term may be used to describe different roles, or two terms may mean the same thing. This confusion is evident among researchers, practitioners, and end users. Because certain animal roles are provided with legal protections and/or government-funding support in some jurisdictions, it is necessary to clearly define the existing terms to avoid confusion. The aim of this paper is to provide operationalized definitions for nine terms, which would be useful in many world regions: “assistance animal”, “companion animal”, “educational/school support animal”, “emotional support animal”, “facility animal”, “service animal”, “skilled companion animal”, “therapy animal”, and “visiting/visitation animal”. At the International Society for Anthrozoology (ISAZ) conferences in 2018 and 2020, over 100 delegates participated in workshops to define these terms, many of whom co-authored this paper. Through an iterative process, we have defined the nine terms and explained how they differ from each other. We recommend phasing out two terms (i.e., “skilled companion animal” and “service animal”) due to overlap with other terms that could potentially exacerbate confusion. The implications for several regions of the world are discussed.

BackgroundThe prevalence of daily or occasional smoking among high school students in Sweden was approximately 20% in 2019, which is problematic since lifestyle behaviors are established in adolescence and track into adulthood. The Nicotine Exit (NEXit) Junior trial was conducted in response to a lack of evidence for the effects of text message smoking cessation interventions among high school students in Sweden.ObjectiveThe aim of this study was to estimate the 3- and 6-month effects of a text messaging intervention among high school students in Sweden on smoking cessation outcomes.MethodsA 2-arm, single-blind randomized controlled trial was employed to estimate the effects of the intervention on smoking cessation in comparison to treatment as usual. Participants were recruited from high schools in Sweden using advertising and promotion by school staff from January 10, 2018, to January 10, 2019. Weekly or daily smokers who were willing to make a quit attempt were eligible for inclusion. Prolonged abstinence and point prevalence of smoking cessation were measured at 3 and 6 months after randomization.ResultsComplete case analysis was possible on 57.9% (310/535) of the participants at 6 months, with no observed statistically significant effect on 5-month prolonged abstinence (odds ratio [OR] 1.27, 95% CI 0.73-2.20; P=.39) or 4-week smoking cessation (OR 1.42; 95% CI 0.83-2.46; P=.20). Sensitivity analyses using imputation yielded similar findings. Unplanned Bayesian analyses showed that the effects of the intervention were in the anticipated direction. The findings were limited by the risk of bias induced by high attrition (42.1%). The trial recruited high school students in a pragmatic setting and included both weekly and daily smokers; thus, generalization to the target population is more direct compared with findings obtained under more strict study procedures.ConclusionsHigher than expected attrition rates to follow-up 6 months after randomization led to null hypothesis tests being underpowered; however, unplanned Bayesian analyses found that the effects of the intervention were in the anticipated direction. Future trials of smoking cessation interventions targeting high school students should aim to prepare strategies for increasing retention to mid- and long-term follow-up.Trial RegistrationIRCTN Registry ISRCTN15396225; https://www.isrctn.com/ISRCTN15396225International Registered Report Identifier (IRRID)RR2-10.1186/s13063-018-3028-2

BACKGROUND A steady decline of the smoking prevalence in Sweden has been recorded over the past decade; however, people still start and continue to smoke. There is a need for effective smoking cessation interventions that can scale to a national level and that are designed to reach individuals requiring smoking cessation support in the general population. OBJECTIVE Previous randomized controlled trials of smoking cessation interventions among high school and university students in Sweden have found consistent evidence that text messaging interventions are effective in helping students quit smoking. However, there are no studies that investigate the effects of text messaging interventions in a more general population. The objective of this study is to estimate the effects of a text messaging intervention on individuals seeking help to quit online and individuals visiting primary health care units. METHODS A 2-arm, parallel-group (1:1), randomized controlled trial will be employed to address the study objectives. The trial will follow a Bayesian group sequential design. Recruitment will be conducted using online advertisement (Google, Bing, and Facebook) and through health care professionals at primary health care units. All participants will receive treatment as usual; however, participants who are allocated to the intervention arm will also be given access to a 12-week text message smoking cessation intervention. Primary outcomes are 8-week prolonged abstinence and 4-week point prevalence, measured 3 months and 6 months postrandomization. Mediator variables (self-efficacy, importance, and know-how) will be measured to estimate causal mediation models. RESULTS Recruitment commenced in September 2020 and will not exceed 24 months. This means that a complete dataset will be available at the latest towards the end of 2022. We expect to publish the findings from this trial by June 2023. CONCLUSIONS This trial will further our understanding of the effects of text messaging interventions among a more general population than has previously been studied. We also aim to learn about differential effects between those who seek support online and those who are given facilitated support at primary health care units. Trial recruitment is limited to the Swedish population; however, a strength of this study is the pragmatic way in which participants are recruited. Through online advertisements, individuals are recruited in reaction to their own interest in seeking help to quit. At primary health care units, individuals who were not necessarily looking for smoking cessation support are given information about the trial. This closely mimics the way the intervention would be disseminated in a real-world setting and may therefore strengthen the argument of generalizability of findings. CLINICALTRIAL ISRCTN 13455271; http://www.isrctn.com/ISRCTN13455271. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/23677

BACKGROUND Several large studies have shown that the risk of cardiovascular, respiratory, and wound-healing complications (including death) within 30 days of surgery is greater for smokers than for nonsmokers. However, there is evidence that even short-term perioperative smoking cessation may reduce postoperative morbidity. Over the past few years, it has become more evident that short message service (SMS)–based interventions can help individuals quit smoking. OBJECTIVE The overall aim of this project is to fill the knowledge gap on whether an SMS-based smoking-cessation intervention can be effective in helping patients stop smoking perioperatively. The aim of this trial is to evaluate the effectiveness of an SMS-based intervention on smoking behavior of patients undergoing elective surgery. METHODS A two-arm parallel-group randomized controlled trial will be conducted at 20 surgical departments in southeast Sweden. Smokers undergoing elective surgery who own a mobile phone will be included. Power calculations indicate that it will be necessary to randomize 434 participants. One group will be given access to a novel 12-week SMS program, which includes daily SMS messages with behavior change–enforcing text content and hyperlinks to interactive modules, while the other group will not be given access to the intervention. Both groups will have access to the surgical departments’ current routine for smoking cessation prior to surgery. Primary outcome measures, prolonged abstinence, and point prevalence of smoking cessation will be measured through questionnaires at 3, 6, and 12 months after randomization. Logistic regression models adjusted using baseline characteristics will be explored to identify potential effects of the intervention. RESULTS Recruitment started in late October 2018 and is expected to last for a maximum of 30 months. The first results are expected to be available approximately 3 months after the final date of recruitment. CONCLUSIONS Owing to the structural problems and scarcity of time and resources, patients at most Swedish surgical departments are simply instructed to quit smoking, and perhaps, referred to a primary health care clinic. An SMS-based smoking-cessation aid can be effective in helping individuals quit smoking and is a very simple and time-efficient tool for surgical departments to use. CLINICALTRIAL ISRCTN Registry ISRCTN33869008; http://www.isrctn.com/ISRCTN33869008 INTERNATIONAL REGISTERED REPOR PRR1-10.2196/12511

The main objective of this study was to investigate the tolerability and safety of the monoaminergic stabilizer (-)-OSU6162 in patients with multiple sclerosis (MS). In addition, a potential therapeutic effect of (-)-OSU6162 with focus on MS-related fatigue was estimated by means of various self-assessment rating scales as well as a clinical investigator-rated scale. In this open-label, single-arm study, 30 MS patients received treatment with the monoaminergic stabilizer (-)-OSU6162 during 12weeks. The dose of (-)-OSU6162 was 15mg twice daily during the first 4-week period, up to 30mg twice daily during the second 4-week period and up to 45mg twice daily during the third 4-week period, with follow-up visits after 16 and 20weeks. MS-related fatigue was rated by the clinical investigator or by self-assessments, using mainly established rating scales. Twenty-five patients completed the study. (-)-OSU6162 was well tolerated by all patients, and no serious adverse events were observed. Therapeutically, improvements were observed with respect to fatigue and mood, as judged by ratings on the Mental Fatigue Scale (MFS), Short Form-36 (SF-36) scale and Beck Depression Inventory (BDI). Furthermore, the large majority of patients were rated as globally improved in the medical observers' rating scale Clinical Global Impression of Change (CGI-C). In view of its good tolerability, (-)-OSU6162 may offer a new treatment option for alleviating mental fatigue, as well as depression, in MS. Larger, randomized double-blind controlled trials are warranted to confirm the present preliminary observations.

BackgroundIn the clinic setting both fasting levels of glucose and the area under the curve (AUC) of glucose, by determination of HbA1c levels, are used for risk assessments, in type 2 diabetes (NIDDM). However little is known about postprandial levels, and hence AUC, regarding other traditional risk factors such as insulin and blood-lipids and how this is affected by different diets.ObjectiveTo study postprandial effects of three diets, during a single day, in NIDDM.MethodsA low-fat diet (45–56 energy-% from carbohydrates), and a low-carbohydrate diet (16–24 energy-% from carbohydrates) was compared with a Mediterranean-style diet (black coffee for breakfast and the same total-caloric intake as the other two diets for lunch with red wine, 32–35 energy−% from carbohydrates) in a randomized cross-over design. Total-caloric intake/test-day at the clinic from food was 1025–1080 kCal in men and 905–984 kCal in women. The test meals were consumed at a diabetes ward under supervision.ResultsTwenty-one participants were recruited and 19 completed the studies. The low-carbohydrate diet induced lower insulin and glucose excursions compared with the low-fat diet (p<0.0005 for both AUC). The insulin-response following the single Mediterranean-style lunch-meal was more pronounced than during the low-fat diet lunch (insulin increase-ratio of the low-fat diet: 4.35±2.2, of Mediterranean-style diet: 8.12±5.2, p = 0.001) while postprandial glucose levels were similar. The increase-ratio of insulin correlated with the elevation of the incretin glucose-dependent insulinotropic-polypeptide following the Mediterranean-style diet lunch (Spearman, r = 0.64, p = 0.003).ConclusionsThe large Mediterranean-style lunch-meal induced similar postprandial glucose-elevations as the low-fat meal despite almost double amount of calories due to a pronounced insulin-increase. This suggests that accumulation of caloric intake from breakfast and lunch to a single large Mediterranean style lunch-meal in NIDDM might be advantageous from a metabolic perspective.Trial RegistrationClinicalTrials.gov NCT01522157 NCT01522157

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