The influence of sociodemographic factors and close relatives at hospital discharge and post hospital care of older people with complex care needs: nurses' perceptions on health inequity in three Nordic cities.

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers' networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient's health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient's health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00701-6.

Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study.

The aim of this study was to compare the efficacy and safety of prolonged (35 days) thromboprophylaxis with a standard length (7 days) regimen of a low molecular weight heparin in patients undergoing total hip arthroplasty. The study was multicentre, randomised, double-blind, and prospective with two groups. Following seven days on a standard length regimen of dalteparin (5000 antifactor Xa units subcutaneously once daily starting 12 h before surgery), patients were randomized to continue the prophylaxis with either subcutaneous injections of dalteparin or placebo injections for a further 28 days. Efficacy was evaluated at the end of the study (day 35) in all patients with bilateral ascending phlebography to detect deep vein thrombosis. Bleeding complications and other adverse events were registered throughout the study period. Three hundred consecutive patients agreed to participate before the operation: 281 were finally randomised and 215 completed the study; two patients died before randomisation; 17 developed deep vein thrombosis; none developed pulmonary embolism; and five of 113 patients (4.4%, 95% CI 1-10%) developed deep vein thrombosis in the dalteparin group, compared with 12 of 102 (11.8%; 95% CI 6-20%) in the placebo group (p=0.039). Deep vein thrombosis in the proximal veins was diagnosed in one patient (0.9%; 95% CI 0-5%) in the dalteparin group, and in five (5.0%; 95% CI 2-11%) in the placebo group (p=0.076). Major bleeding was observed in one patient in the placebo group; minor bleeding complications and adverse events were equally distributed between the groups. We concluded that prolonged (35 days) thrombo prophylaxis with dalteparin is more effective than a standard length (7 days) regimen without increased risk of bleeding complications or other adverse events.

External tissue stretching for closing skin defects in 22 patients.

In this prospective study, we treated 12 women and 10 men with a newly developed skin-stretching system. The stretching device was used for the closure of 9 fasciotomies and for preoperative skin extension before excision of 6 tattooes, 7 splitskin transplants, 4 giant naevi, and 3 scars. The stretching device was placed under the skin, using local anesthesia. The patient stretched the skin. The mean stretching time was 4 (2-11) days. 20 patients completed the expansion successfully, with no pain or only slight discomfort. In 2 cases, we observed minor complications during the expansion. The external skin-stretching system can be used to obtain primary closure of defects where splitskin transplants otherwise would be necessary. The method can be applied in out-patients, using local anesthesia.

Observer variation in histological classification of cutaneous malignant melanoma.

To evaluate the variations within and between observers in the interpretation of important histological prognostic factors, a series of 96 melanoma patients was randomly selected from a database of 1691 patients with cutaneous malignant melanoma. The stained sections were examined on two occasions by four experienced pathologists. Analysis by observed agreement and kappa statistics showed maximal tumour thickness to be the best reproducible variable, with ulceration the second best. Regression was the least reproducible, with level of invasion and type of melanoma in the mid range. Intra-observer variation was uniformly less than inter-observer variation for each variable. For tumour thickness a variance component analysis was done to quantify the variability further. The clinician should not base his choice of treatment entirely on the microscopic classification but take into consideration the clinical course and appearance of the tumour.

Pressure-controlled palpation: a new technique which increases the reliability of manual palpation.

The objective of the present study was to investigate whether the reliability of tenderness evaluation can be increased by using a new technique called "pressure-controlled palpation" (pcp). The technique has been made possible by a newly invented piece of equipment called a palpometer, with which a pressure-sensitive plastic film attached to the index finger records the pressure exerted. In 15 patients with chronic tension-type headache and in 15 healthy volunteers, 2 investigators studied myofascial tenderness using conventional palpation and pressure-controlled palpation. Tenderness was scored on a 4-point scale in each of the examined pericranial regions. The sum of tenderness scores recorded by two observers using conventional palpation differed significantly (p = 0.0003), while results did not differ between observers using pressure-controlled palpation (p = 0.89). During palpation with seven different pressure intensities a positive and linear relation between pressure and pain intensity was found (p = 0.00006). Pain intensity reported by the subjects correlated highly with tenderness scored by the observer (rs = 0.95, p < 0.0001). These results demonstrate for the first time that tenderness scores can be compared between observers if palpation pressure is controlled. Pressure-controlled palpation represents a major improvement on current palpation techniques and should be standard in future research on myofascial pain disorders.

Synovial haemangiopericytoma of the knee joint.

We report a case of haemangiopericytoma occurring intra-articularly in the synovium of the knee joint. This is a rare tumour which, as far as is known to the authors, has not previously been described in a subsynovial site.

Adult, acquired reactive perforating collagenosis. Report of a case including ultrastructural findings.

A case of reactive perforating collagenosis in an adult male patient with chronic renal failure. Pruritic, umbilicate papules, showing extrusion of collagen fibers through the epidermis were detected histopathologically. Electron microscopy showed absence of basal membrane beneath the perforation and collagen fibers with preserved periodicity passing through widened intercellular spaces with islands of cytoplasmic material.

ARDS after accidental inhalation of zinc chloride smoke.

Five soldiers were injured by inhalation of hexite smoke (ZnCl2) during military training. Two soldiers, not wearing gas masks breathed hexite for 1 or 2 min, they slowly developed severe adult respiratory distress syndrome (ARDS) over the ensuing 2 weeks. This slow, progressive clinical course has not been previously described. In both patients, an increased plasma zinc concentration was measured 3 weeks after the incident. Intravenous and nebulized acetylcysteine increased the urinary excretion of zinc, and briefly decreased the plasma levels. In an attempt to arrest collagen deposition in the lungs, L-3,4 dehydroproline was administered. Both patients died of severe respiratory failure (25 and 32 days after inhalation). At autopsy diffuse microvascular obliteration, widespread occlusion of the pulmonary arteries and extensive interstitial and intra-alveolar fibrosis was observed. Three soldiers wearing ill fitting gas masks, immediately developed severe coughing and dyspnea. They improved, and 12 months after exposure their lung function tests were nearly normal, but they still had slight dyspnea on exercise.

Prenatal diagnosis of trisomy 20 mosaicism indicating esophageal and rectal origin.

Trisomy 20 mosaicism in cultured amniotic fluid cells has in only a few cases been confirmed in fetal tissue. This may lead to the assumption that the trisomic cells are of extra-fetal origin and interruption of the pregnancy is not advisable. Chromosome analysis of numerous fetal tissues indicated in two cases the presence of one or more trisomy 20 cell clones in rectum and esophagus, respectively. The clinical significance of trisomy 20 mosaicism in single organs remains to be elucidated. Besides the karyotype, genetic counselling should take into account all accessible information of the pregnancy, e.g. ultra-sound, serum alpha-fetoprotein values and obstetrical history.

Acrokeratosis paraneoplastica (Bazex' syndrome).

A 63-year-old man had acrokeratosis paraneoplastica (Bazex' syndrome) characterized by violaceous erythema and scaling of the fingers, toes, nose, and aural helices. Severe nail dystrophy was present. Extensive examination of the patient for malignant neoplasms a few months after the initial appearance of the skin changes disclosed no abnormalities, but one year after onset, an epidermoid carcinoma of the lung was found.

Malignant histiocytosis. The diagnosis based on chromosomal, immunologic and histiopathologic analysis.

A 38-year-old female suffered for several months from persistent fever without signs of infectious or immunologic disease. 57Co-bleomycin scintigraphy revealed abnormal concentration in the liver. Following a diagnostic laparotomy, the patient died from abdominal haemorrhage. Malignant cell infiltration was demonstrated in a biopsy from the liver. Histiocytic cells were demonstrated in a bone marrow smear obtained shortly before death. Investigation of cultured lymphocytes obtained from the patient the day before she died showed deficiency of T-lymphocytes. Investigations of chromosomes delineated several clones with polyploidi. The diagnosis of malignant histiocytosis was based on erythrophagocytosis, and immunologic and chromosomal aberrations. If malignant histiocytosis is the primary disease, a terminal stage of different diseases or a sign of complication secondary to immuno incompetence (e.g. virus infection) is an open question.

Permanent cardiac pacemakers implanted in the pleural space.

Intrapleural implantation is recommended for children, active adolescents and adults, psychiatric patients, and infection-prone patients because of the protection afforded by the pleural space. The implantation technique is briefly described. Complications include diaphragmatic muscle stimulation (with a unipolar unit) and continuous migration of the pulse generator. The advantages of this implantation site include the following (1) reduced risk of lead fracture, (2) protection from physical trauma, (3) reduced risk of infection and erosion. (4) improved cosmetic appearance, and (5) minimized child/generator size disproportion. In one groups of patients undergoing both standard and intrapleural implantation, the number of pacing months per surgical procedure was increased from 5.1 months (standard implant) to 26.2 months (intrapleural implant). Intrapleural implantation may be considered the generator position of choice for the small percentage of patients who require special pacing system protection.

The extent of carcinoma in situ in urinary bladders with primary carcinomas.

The occurrence of carcinoma in situ was examined in a consequtive series of cystectomy specimens from 43 patients. All patients were suffering from or had been suffering from primary bladder cancer. Carcinoma in situ was defined as a definitive polymorphia of enlarged nuclei with abnormal chromatin structure in non-tumour bearing areas. It was found in 26 bladders. By means of a systematic technique of cutting the specimens, the extent of the alterations was quantitied, relating the number of blocks containing the alteration to the total number of blocks in which the changes possibly might be present. The extent of carcinoma in situ ranged from 2 to 81% with an average of 20%. The distribution of the alterations was unpredictable, often strongly focal, most often in continuation of the tumour. In one specimen, the margins of resection were involved. The extent was largest in bladders with poorly differentiated tumours. A temporal relationship between in situ carcinoma and invasive carcinoma could not be shown, as regards tumour size and duration of clinical symptoms. The morphology of the changes is discussed seen in the light of variations in the normal epithelium lining the lower urinary tract. Minor degrees of atypia of the epithelium showed rather bad reproduction. The dominating occurrence of carcinoma in situ in bladders with poorly differentiated tumours may either be a manifestation of a biological difference between tumours of different grades of differentiation or that the morphological criteria used correspond to the in situ type of poorly differentiated tumours.

Types of metaplasia in forty urothelial bladder carcinomas. A systematic histological investigation.

In a systematic study of bladders from consecutively cystectomized patients, 40 primary urinary bladder carcinomas were examined with regard to the type of differentiation. Metaplastic areas were found in 24 of the tumours. A positive reaction of keratin to Kreybergs stain was required for the definition squamous metaplasia. Squamous areas were found in 16 of the tumours. In 4 tumours there was, in addition to squamos metaplasia, glandular metaplasia which was defined as definite glandular tissue with dysplasia of the epithelium. In 4 tumours, glandular metaplasia was also present in addition to the urothelial carcinoma. In 18 cases, metaplastic changes were present in the luminal portion of the tumour from which the biopsy material and desquaminated material originated. The occurrence of metaplasia was related to the degree of differentiation of the urothelial part of the tumour. Metaplastic changes were most frequent in the poorly differentiated tumours. The biopsies obtained pre-operatively permitted of the diagnosis metaplasia being made in 15 cases, while the cytological material suggested metaplastic changes in 4 cases only. The biological function of metaplasia is unknow. The possibility that these areas will react differently to radiation and chemotherapy is present and the frequency of such changes would suggest that their importance should be studied by their registration as mixed forms as stated by WHO.