Child Sexual Abuse-Challenging Conditions for Adult Oral Health: A Qualitative Study.

The aim was to analyze perceptions of oral health in adults who have been exposed to child sexual abuse. Eleven participants (10 women), 19 to 56 y of age, who had experienced sexual abuse as children were purposively selected and interviewed in-depth. The participants were encouraged to describe how they perceived the effect of the sexual abuse on their oral health as adults. The interviews were recorded digitally and transcribed verbatim. The collected material was analyzed according to qualitative content analysis. The theme "challenging conditions for maintaining oral health" was identified, comprising 2 categories: first, "the emotional significance," with the subcategories 1) emotional barriers and 2) powerful relief, and second, "the obstacles to oral health," with the subcategories 1) daily self-care with complications and 2) dental appointments with difficulties. The findings indicate that the experience of sexual abuse during childhood can have a negative impact on oral care in adulthood. The informants stated that oral health was of utmost importance but also associated with strong emotions. There were obstacles to maintenance of oral health that were difficult to surmount.Knowledge Transfer Statement:The study provides access to the attitudes of survivors of child sexual abuse regarding oral health and the needs and obstacles that they experience. This is important knowledge for dental professionals to optimize dental care.

Process evaluation of a cluster randomised intervention in Swedish primary care: using care managers in collaborative care to improve care quality for patients with depression.

BACKGROUND: The collaborative care model with a care manager has previously generated beneficial results for patients with depression in terms of decreased burden of depression symptoms. A care manager function has been tested in Sweden in the PRIM-CARE RCT with successful results. The aim of the present study was to evaluate the process of implementing care managers in collaborative care for patients with depression in Swedish primary health care in the PRIM-CARE RCT. METHODS: The study followed UK Medical Research Council guidance for process evaluation. Field notes from the implementation of the PRIM - CARE RCT were used, as well as data collected from five focus group discussions with General Practitioners (n = 29) and three focus group discussions with care managers (n = 11). Data were analysed with content analysis. RESULTS: Training sessions, careful preparation and extensive initial support to the care manager and staff at the Primary Care Centres were important ingredients in the implementation. The close access to facilitators, the recurrent peer support meetings, and the weekly newsletter strengthened the care manager function. CONCLUSIONS: A complex intervention adapted to the Swedish primary care context focusing on a care manager function for patients with depression could be performed through a stepwise implementation process. Financial support from the health care regions included in the study helped to reduce the impact of identified barriers. This process evaluation has revealed new and important knowledge for primary care development concerning infrastructure and organization building, knowledge sharing, and facilitating factors and barriers. TRIAL REGISTRATION: NCT02378272 Care Manager - Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM - CARE). Registered March 4 2015. Retrospectively registered.

Implementation of the integrated palliative care outcome scale in acute care settings - a feasibility study.

OBJECTIVE: Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings. METHOD: A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals.ResultFactors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers' involvement in the implementation differed between the units.Significance of the resultsThe feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.

Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care.

Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants.

OBJECTIVE: To investigate the influence of co-care facilities and amount of skin-to-skin contact during Neonatal Intensive Care Unit (NICU) stay on maternal stress in mothers of preterm infants at two months corrected age. METHODS: A prospective cohort study that involved 300 mothers of pre-term infants was conducted in four NICUs (two with co-care facilities and two with non co-care) in Sweden. Data on duration of skin-to-skin contact per day for all days admitted to the NICU were collected using self-reports. Maternal stress was measured by the Swedish Parental Stress Questionnaire (SPSQ) at two months of infant's corrected age. RESULTS: Mothers whose infants were cared for in a NICU with co-care facilities reported significantly lower levels of stress in the dimension of 'incompetence' compared to mothers whose infants had been cared for in non co-care NICUs. The amount of skin-to-skin experienced during the neonatal stay was not significantly associated with levels of maternal stress at two months corrected age. CONCLUSION: The finding that mothers who do not experience co-care facilities experience greater levels of stress in relation to feelings of incompetence is of concern. Improvements to NICU environments are needed to ensure that mother-infant dyads are not separated.

Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam.

BACKGROUND: If millions of neonatal deaths each year are to be prevented, one crucial component that must be improved is adequate care-seeking behaviour and effective use of existing health care systems. We have investigated these factors in relation to delivery and the neonatal period in a province in Northern Vietnam, a setting currently in socio-economic transition. METHODS: Information on births and neonatal deaths between January and December 2005 in Quang Ninh province was collected. Narratives of the neonatal deaths were gathered and information about care-seeking in relation to delivery and illness was extracted. This information was then compared with the time and place of delivery and death. RESULTS: We registered 17,519 births and 284 neonatal deaths occurring between January and December 2005. The neonatal mortality rate varied from 7.5/1000 to 38/1000, depending on the place of delivery. A quarter of the neonatal deaths had no contact with the health-care system at the time of death. Neonatal death within 24 hours of birth was more likely when the mother did not seek care at the time of delivery, or did so at the lowest level of the system (chi2=35.5, p<0.001). Mothers of ethnic minorities were more likely to exhibit this care-seeking behaviour at delivery. CONCLUSION: Further improvement in neonatal survival can be achieved by changes in health system utilisation that aim to secure safe delivery for pregnant women. More efforts at local level are needed to encourage adequate care-seeking.

Effect of serotonin on small intestinal contractility in healthy volunteers.

The physiological significance of serotonin released into the intestinal lumen for the regulation of motility is unknown in humans. The aim of this study was to evaluate the effect of serotonin infused into the lumen of the gastric antrum, duodenum or the jejunum, on antro-duodeno-jejunal contractility in healthy human volunteers. Manometric recordings were obtained and the effects of either a standard meal, continuous intravenous infusion of serotonin (20 nmol/kg/min) or intraluminal bolus infusions of graded doses of serotonin (2.5, 25 or 250 nmol) were compared. In addition, platelet-depleted plasma levels of serotonin, blood pressure, heart rate and electrocardiogram were evaluated. All subjects showed similar results. Intravenous serotonin increased migrating motor complex phase III frequency 3-fold and migrating velocity 2-fold. Intraluminal infusion of serotonin did not change contractile activity. Platelet-depleted-plasma levels of serotonin increased 2-fold following both intravenous and high doses of intraluminal infusions of serotonin. All subjects reported minor short-lived adverse effects following intravenous serotonin stimulation, while only half of the subjects reported minor short-lived adverse effects following intraluminal serotonin stimulations. We conclude that exogenous serotonin in the lumen of the upper part of the small intestine does not seem to change antro-duodeno-jejunal contractility significantly in healthy adult volunteers.

Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants.

AIM: To describe the impact of prematurity, size at birth, neonatal disorders and the families' socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants. METHODS: Prospective population-based cohort study. Data on breastfeeding, registered in databases in two Swedish counties in 1993-2001, were matched with data from two national registries: the Medical Birth Registry and Statistics Sweden. Mothers of 225 very preterm singleton infants were identified and included. RESULTS: Seventy-nine percent of the mothers breastfed at 2 months, 62% at 4 months, 45% at 6 months, 22% at 9 months and 12% at 12 months. Prematurity, size at birth and neonatal disorders did not show an effect on breastfeeding duration. Being adversely exposed to any of the SES factors (maternal education, unemployment benefit, social welfare and equivalent disposable income in the household) was significantly associated with earlier weaning up to 6 months of infants' postnatal age. CONCLUSIONS: This study shows new and noteworthy results concerning breastfeeding duration in mothers of very preterm infants, which was not influenced by degree of prematurity, size at birth or neonatal disorders but was affected by SES. This highlights the need for improved support of socioeconomically disadvantaged mothers, during and after the hospital stay.

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis.

BACKGROUND: This randomized clinical trial compared long-term outcome after antireflux surgery with acid inhibition therapy in the treatment of chronic gastro-oesophageal reflux disease (GORD). METHODS: Patients with chronic GORD and oesophagitis verified at endoscopy were allocated to treatment with omeprazole (154 patients) or antireflux surgery (144). After 7 years of follow-up, 119 patients in the omeprazole arm and 99 who had antireflux surgery were available for evaluation. The primary outcome variable was the cumulative proportion of patients in whom treatment failed. Secondary objectives were evaluation of the treatment failure rate after dose adjustment of omeprazole, safety, and the frequency and severity of post-fundoplication complaints. RESULTS: The proportion of patients in whom treatment did not fail during the 7 years was significantly higher in the surgical than in the medical group (66.7 versus 46.7 per cent respectively; P=0.002). A smaller difference remained after dose adjustment in the omeprazole group (P=0.045). More patients in the surgical group complained of symptoms such as dysphagia, inability to belch or vomit, and rectal flatulence. These complaints were fairly stable throughout the study interval. The mean daily dose of omeprazole was 22.8, 24.1, 24.3 and 24.3 mg at 1, 3, 5 and 7 years respectively. CONCLUSION: Chronic GORD can be treated effectively by either antireflux surgery or omeprazole therapy. After 7 years, surgery was more effective in controlling overall disease symptoms, but specific post-fundoplication complaints remained a problem. There appeared to be no dose escalation of omeprazole with time.

Serotonin and superior mesenteric artery resistance index.

OBJECTIVE: Serotonin is a vasoactive neuroendocrine substance and serotonergic drugs are promising agents for the treatment of functional gastrointestinal disorders. The effect of serotonin on superior mesenteric blood flow in humans is unknown. The aim of this study was to examine the effect of exogenous serotonin on superior mesenteric artery blood flow, as estimated by the resistance index with Doppler ultrasound, in healthy human volunteers. MATERIAL AND METHODS: Six fasting healthy adult volunteers of both genders were studied. Transabdominal Doppler ultrasound was used to evaluate the effects of either a standard meal or intravenous infusion of serotonin (2.5-20 nmol kg-1 min-1) on the superior mesenteric artery resistance index, platelet-depleted plasma levels of serotonin, blood pressure, heart rate and electrocardiogram. RESULTS: All subjects had the same patterns of response to meal and serotonin stimulation. Meal stimulation decreased the mean resistance index from 0.84+/-0.04 to 0.72+/-0.02 (p = 0.0004) and increased platelet-depleted-plasma levels of serotonin from 50+/-36 to 61+/-46 nmol L-1 (p = 0.04). Serotonin stimulation increased the mean resistance index from 0.82+/-0.04 to 0.88+/-0.03 (p = 0.006) and mean platelet-depleted-plasma levels of serotonin from 44+/-24 to 83+/-37 nmol L-1 (p = 0.03). Most subjects reported minor short-lived adverse effects. Electrocardiogram results were unchanged during all examinations. CONCLUSIONS: We conclude that intravenous infusion of serotonin increases the resistance index of the superior mesenteric artery (increases downstream resistance) in healthy adult volunteers.

Changes of gastric mucosal architecture during long-term omeprazole therapy: results of a randomized clinical trial.

BACKGROUND: The impact of long-term acid suppression on the gastric mucosa remains controversial. AIM: To report further observations on an established cohort of patients with gastro-oesophageal reflux disease, after 7 years of follow-up. METHODS: Of the original cohort randomized to either antireflux surgery or omeprazole, 117 and 98 patients remained in the medical and surgical arms, respectively. Gastric biopsies were taken at baseline and throughout the study. RESULTS: Fifty-three antireflux surgery and 39 omeprazole-treated patients had Helicobacter pylori infection at randomization. Eighty-three omeprazole-treated and 60 antireflux surgery patients remained H. pylori negative over the 7 years, and no change was observed in mucosal morphology except for a change in endocrine cell population (linear and diffuse hyperplasia, P = 0.03). During the 7-year study many patients, who were initially H. pylori infected, had the infection eradicated leaving only 13 omeprazole and 12 antireflux surgery patients still infected. In these patients, omeprazole induced a deterioration of the mucosal inflammation scores (P = 0.01) with a numerical increase of glandular atrophy. CONCLUSIONS: Long-term omeprazole therapy does not alter the exocrine oxyntic mucosal morphology in H. pylori-negative patients, but mucosal endocrine cells appear to be under proliferative stimulation; in H. pylori-positive patients there are changes in mucosal inflammation and atrophy.

Research utilization among dental hygienists in Sweden--a national survey.

Over the last decade evidence-based practice has become increasingly important in health care as an approach to improve patient outcomes. It is vital that dental hygienists, like other health professionals, use research findings to inform clinical practice. The objective of the present study was to investigate the extent of research utilization among dental hygienists in Sweden and to investigate the relationship between level of education and factors related to research utilization. A random sample of 261 dental hygienists in Sweden, 113 with 1 year and 148 with 2-year education, responded to a postal questionnaire covering various aspects of research utilization, i.e. their attitudes towards research, availability and support for the implementation of research findings, use of research in daily practice, their activity in seeking new research findings and their participation in a range of research-related activities. Dental hygienists with 2-year education had a more positive attitude towards research, used research to a greater extent and were more active in seeking new research findings than dental hygienists with 1-year education. Overall, relatively few dental hygienists reported that they implemented research findings in practice; the most frequently reported activity concerned reading research articles in professional journals. The conclusions are that the length of dental hygiene education is a key factor influencing the application of research findings to practice. One-year education appears to be inadequate to achieve evidence-based practice. Moreover, not even two years of formal education guarantees necessary competence in research for evidence-based dental hygiene practice.

Functional consequences of stress-related suppression of adult hippocampal neurogenesis - a novel hypothesis on the neurobiology of burnout.

BACKGROUND: Burnout is generally recognized as a work-related stress-induced condition associated with memory problems, fatigue, a sense of inadequacy, and depressed mood. Neurogenesis, the formation of new neurons in the human adult brain, provides a newly discovered dimension of brain plasticity. OBJECTIVES: In a novel theory, we propose that the failure of adult hippocampal neurogenesis may provide the biological and cellular basis for altered brain plasticity in stress-related syndromes like burnout. METHODS: A number of recent animal studies have shown that the rate of neurogenesis in the adult hippocampus may provide an important neurobiological correlate to the symptoms of stress. RESULTS: As of yet, the normal physiological function of new neurons in the adult hippocampus remains unresolved although a number of studies and reviews indicate the importance of neurogenesis for memory and learning. CONCLUSION: In line with this hypothesis, we propose burnout to be an exponent of stress-mediated decrease in adult neurogenesis leading to a decreased ability to cope with stress through decreased hippocampal function possibly involving a disturbed hippocampal regulation of the hypothalamo-pituitary-adrenal axis (HPA axis).

Identifying response to acid suppressive therapy in functional dyspepsia using a random starting day trial--is gastro-oesophageal reflux important?

BACKGROUND: Single subject trials offer an alternative approach to identify and characterize responders to a specific treatment. AIM: To test a new single subject trials design, called random starting day trial, to identify acid-related symptoms in dyspepsia. METHODS: A total of 119 patients with functional dyspepsia entered a 12-day, double-blind random starting day trial. All patients started on placebo and switched to omeprazole 80 mg/day at a randomized and blinded day between day 5 and day 9, with active treatment continuing for the rest of the trial. Based on changes of a daily symptom score, response was defined as a sustained > or =50% reduction of symptoms within 3 days of active treatment. RESULTS: Thirteen of 119 patients (11%) were classified as spontaneous responders because of complete symptom relief before switching to omeprazole. Of the remaining 106 patients, 15 (15.6%) were classified as responders. Five of six (83%) responders compared with 28 of 53 (53%) non-responders had pathological reflux. Multivariate testing identified symptoms suggestive of gastro-oesophageal reflux predictive of response. CONCLUSIONS: The random starting day trial design could identify a subset of dyspeptic patients with a uniform symptomatic response to acid-suppressive therapy. Response seems to be associated with gastro-oesophageal reflux. The random starting day trial needs to be further validated to be considered as a reliable instrument in clinical research.

Progress of unit based quality improvement: an evaluation of a support strategy.

OBJECTIVE: To evaluate a strategy for supporting nurses to work with quality improvement (QI). DESIGN: Post-intervention evaluation. Study participants and intervention: 240 nurses participated in a uniformly designed 4 day basic training course in applying a model for QI. Of these, 156 nurses from over 50 healthcare institutions constituted the generic education (GE) group while 84 nurses from 42 neonatal units took part in a project to develop national guidelines, constituting the targeted intervention (TI) group. METHOD: Postal questionnaire 4 years after the training courses. RESULTS: The response rate was 80% in the TI group and 64% in the GE group. Nurses in the TI group had a significantly higher rate in completing all phases of the QI cycle (p=0.0002). With no differences between the groups, 39% of all nurses were still involved in QI work 4 years after the training courses. Three factors were significantly related to nurses continuing their involvement in QI projects: remaining employed on the same unit (OR 11.3), taking courses in nursing science (OR 4.1), and maintenance of the same QI model (OR 3.1). Reported motives for remaining active in QI work were the enhancement of knowledge, influence over clinical practice, and development as a nurse. Reasons for discontinuation were organisational restructuring, a lack of facilitation and knowledge, and change of workplace. CONCLUSIONS: Participation in a national guideline project, including a common focus for improvement, facilitation and opportunities for networking, seems to have enhanced the ability to carry out the process of QI, but not to sustain the QI work over a longer period.

Follow-up of acute pyelonephritis in children by Tc-99m DMSA scintigraphy: quantitative and qualitative assessment.

PURPOSE: The author's goal was to create a system to identify children at risk for development of progressive renal damage. METHODS: Thirty-four children were examined with Tc-99m DMSA scintigraphy in the acute stage of an initial episode of pyelonephritis, after 6 months, and again after 1 year. The scintigraphic findings were correlated with clinical and laboratory data. RESULTS: All children had parenchymal defects in the acute stage: 93% of the kidneys and 85% bilaterally. After 6 months, the defects had diminished or disappeared in 66% of the kidneys. New defects appeared in 22%. At 1 year, no further improvement was seen in the kidneys, with an improved or unchanged pattern at 6 months. New defects appeared in 34%. Mean kidney activity uptake expressed as the percentage of administered dose (KU/AD), was low in the acute stage, increased at 6 months, with no further significant increase at 1 year. Eighty-three percent of children with urine cultures growing > or = 104 bacteria/ml at follow-up had decreased KU/AD values, whereas all children with urine cultures growing < 104 bacteria/ml had increased KU/AD values. CONCLUSIONS: Quantitative assessment increases the sensitivity of Tc-99m DMSA scintigraphy. Follow-up with this method makes it possible to identify the children with decreasing renal tubular function who may be at risk for progressive renal damage. Moderate bacteruria of 104 bacteria/ml urine is associated with deterioration of renal tubular function.

Rhinosporidiosis in a domestic cat.

Rhinosporidiosis was diagnosed in a domestic shorthair cat from a suburb of Washington DC, USA. The clinical presentation of protracted sneezing and epistaxis was associated with a polypoid lesion in the right nostril. Light microscopic examination revealed a polypoid lesion with numerous sporangia containing maturing endospores. Free endospores were present in the stroma of the polyp and lumen of the nasal cavity. Transmission electron microscopy revealed ultrastructural features typical of Rhinosporidium seeberi. The case was followed clinically for a total of 70 months and there were five attempts at surgical excision. This is the first reported case of rhinosporidiosis in a domestic cat.

National guidelines for Swedish neonatal nursing care: evaluation of clinical application.

OBJECTIVE: To evaluate the clinical application of national guidelines for neonatal nursing. DESIGN: Questionnaire survey. SETTING: Thirty-nine neonatal care units in Sweden. STUDY PARTICIPANTS: Thirty-five of 39 nurse managers at all Swedish neonatal care units. INTERVENTION: Thirteen clinical guidelines for neonatal nursing care were presented in 1997. Recommendations on evidence-based nursing care and auditing measures were given. Most neonatal units in Sweden participated in the guideline development. MAIN OUTCOME MEASURES: Extent of guideline application, ways in which the guidelines were used and perceived usefulness. RESULTS: The guidelines were applied to different extents in 30 of the 35 units. Almost all the guidelines were applied, especially those covering general nursing care. In total, 72 Quality Improvement (QI) projects were reported, of which 51 concerned specific topics covered in the guidelines. Twenty units applied the guidelines as a starting point for QI. Four units evaluated nursing practice against the guidelines. Four factors [Dynamic Standard Setting System (DySSSy) as the QI method, > or = 4 years of practice as nurse manager, experience of nursing research, and good staff resources] were closely related to a more extensive application of the guidelines. Units with both a nurse manager and an assistant nurse manager were more likely to have used the guidelines as the basis for changing clinical practice. CONCLUSIONS: The guidelines were successfully disseminated and diffused, but practitioner involvement in guideline development did not guarantee implementation. Downsizing, leadership and facilitation seemed to be crucial factors when getting evidence into practice. Limited occurrence of evaluations of clinical practice against guideline recommendations suggests a need for valid and user-friendly measures.