Development and validation of a model to predict incident chronic liver disease in the general population: The CLivD score.

BACKGROUND & AIMS: Current screening strategies for chronic liver disease focus on detection of subclinical advanced liver fibrosis but cannot identify those at high future risk of severe liver disease. Our aim was to develop and validate a risk prediction model for incident chronic liver disease in the general population based on widely available factors. METHODS: Multivariable Cox regression analyses were used to develop prediction models for liver-related outcomes with and without laboratory measures (Modellab and Modelnon-lab) in 25,760 individuals aged 40-70 years. Their data were sourced from the Finnish population-based health examination surveys FINRISK 1992-2012 and Health 2000 (derivation cohort). The models were externally validated in the Whitehall II (n = 5,058) and Copenhagen City Heart Study (CCHS) (n = 3,049) cohorts. RESULTS: The absolute rate of incident liver outcomes per 100,000 person-years ranged from 53 to 144. The final prediction model included age, sex, alcohol use (drinks/week), waist-hip ratio, diabetes, and smoking, and Modellab also included gamma-glutamyltransferase values. Internally validated Wolbers' C-statistics were 0.77 for Modellab and 0.75 for Modelnon-lab, while apparent 15-year AUCs were 0.84 (95% CI 0.75-0.93) and 0.82 (95% CI 0.74-0.91). The models identified a small proportion (<2%) of the population with >10% absolute 15-year risk for liver events. Of all liver events, only 10% occurred in participants in the lowest risk category. In the validation cohorts, 15-year AUCs were 0.78 (Modellab) and 0.65 (Modelnon-lab) in the CCHS cohort, and 0.78 (Modelnon-lab) in the Whitehall II cohort. CONCLUSIONS: Based on widely available risk factors, the Chronic Liver Disease (CLivD) score can be used to predict risk of future advanced liver disease in the general population. LAY SUMMARY: Liver disease often progresses silently without symptoms and thus the diagnosis is often delayed until severe complications occur and prognosis becomes poor. In order to identify individuals in the general population who have a high risk of developing severe liver disease in the future, we developed and validated a Chronic Liver Disease (CLivD) risk prediction score, based on age, sex, alcohol use, waist-hip ratio, diabetes, and smoking, with or without measurement of the liver enzyme gamma-glutamyltransferase. The CLivD score can be used as part of health counseling, and for planning further liver investigations and follow-up.

Factors determining nurses' knowledge of evidence-based pressure ulcer prevention practices in Finland: a correlational cross-sectional study.

BACKGROUND: Pressure ulcers cause economic burden, human suffering, pain and decreased health-related quality of life in patients. Pressure ulcers are preventable in most cases, and nursing staff knowledge is a key factor in successful pressure ulcer prevention. Further evidence is needed to better tailor pressure ulcer prevention training programmes to the nursing staff. AIM: To evaluate the level of nursing staff knowledge about evidence-based pressure ulcer prevention practices in both primary and specialised care, and to identify what factors determine nurses' knowledge levels. METHODS: A correlational, cross-sectional study was conducted from 2018 to 2019 in two hospital districts in Finland. The Pressure Ulcer Prevention Knowledge test was used to collect data, and the Attitude towards Pressure ulcer Prevention (APuP) instrument was used as a background variable. The data were statistically analysed with Wilcoxon and Kruskal-Wallis tests, Spearman correlations and multiple linear regression. RESULTS: The pressure ulcer prevention knowledge of the participating registered nurses, practical nurses and ward managers (N = 554) was on average 24.40 (max. 35.00). There was no difference in the participants' knowledge based on the type of unit in which they were working (primary or specialised care). The participants' attitudes (p < 0.0001), current position (p = 0.0042), frequency of taking care of patients with pressure ulcers (p = 0.0001) and self-evaluated training needs (p < 0.0001) independently explained the variation in the knowledge scores. CONCLUSIONS: Special attention needs to be paid to the knowledge of those nurses working in positions that require lower levels of education and those who rarely take care of patients with pressure ulcers. Supporting nurses' positive attitudes towards pressure ulcer prevention should be an essential part of pressure ulcer prevention training. Nurses' self-evaluations of their training needs can be used to target training. The limitations of the study should be considered when generalising the results.

Consistent Practices in Pressure Injury Prevention at Long-term Care Facilities.

OBJECTIVE: To examine the use of consistent practice in pressure injury (PI) prevention based on international guidelines at long-term care facilities in Finland. METHODS: A correlational cross-sectional design was used. The authors collected data from 84 contact persons within 62 participating long-term care facilities in Finland using the Pressure Ulcer Prevention Practice instrument. RESULTS: According to the respondents, the PI prevention strategies practiced most often were skin assessment and skin care; nutrition was the prevention used least often. Consistent practices relating to repositioning were most frequently agreed upon, whereas those relating to risk assessment were least frequently agreed upon. Some of the demographic factors of respondents, including knowledge level and reading of PI prevention guidelines and articles, were associated with the frequency of prevention practices. CONCLUSIONS: Although respondents reported a moderate level of PI prevention based on international guidelines, there were often no consistent practices in the units. Further education about PI prevention might improve the consistent practice of evidence-based PI prevention.

Consistent practices in pressure ulcer prevention based on international care guidelines: A cross-sectional study.

The use of consistent and evidence-based practices is essential in terms of patient safety and quality of care. The purpose of this study was to describe the use of consistent practices in PU prevention based on international care guidelines and to assess the validity and reliability of the pressure ulcer prevention practice (PUPreP) instrument. The data (n = 554) were collected between 2018 and 2019 from nursing professionals working at two hospital districts in Finland using the PUPreP instrument. The instrument consisted of 42 items assessing participants' perceptions of the frequencies of pressure ulcer prevention practices with the following scale: never, sometimes, often, always. The data were analysed using statistical analysis. According to the results, the use of pressure ulcer prevention practices was more frequently described as often. The most frequently used prevention practice was repositioning, and the least frequently used practice was nutrition. Factors related to nursing professionals' pressure ulcer prevention practices were the working sector, education and working frequency in pressure ulcer prevention, and early identification of pressure ulcers. The study results suggest that the evidence-based pressure ulcer prevention practices were followed at a moderate level by nurses. The PuPreP instrument demonstrated validity and reliability, but further development is needed.

Attitudes of nursing staff towards pressure ulcer prevention in primary and specialised health care: A correlational cross-sectional study.

The aim of this correlational, cross-sectional study was to assess the pressure ulcer prevention attitudes of the nursing staff and to identify factors associated with it both in primary and special health care. The study was conducted with nursing staff (N = 554) working in primary and special health care units in two hospital districts in Finlandin 2018 to 2019. Attitude towards Pressure ulcer Prevention instrument was used for data collection. Demographic data, Pressure Ulcer Prevention Knowledge test, and Pressure Ulcer Prevention Practice instrument were used as background variables. Data were analysed with statistical tests. Nursing staff working in primary care (n = 327) had more positive attitudes towards pressure ulcer prevention than those in specialised care (n = 209; P = .047). Working as a wound care nurse (P = .0005), working experience after graduation (P = .0017), self-reported pressure ulcer prevention and early detection skills (P < .0001), pressure ulcer prevention knowledge (P = .0002), and views about the realisation of their unit's pressure ulcer prevention practices (P < .0001) independently explained variation in participants' attitudes. Attention should be placed on the pressure ulcer prevention attitudes of nurses who are less experienced or less skilled and who have lower pressure ulcer prevention knowledge. Positive organisational culture towards evidence-based pressure ulcer prevention practices should be promoted.

Risks of Light and Moderate Alcohol Use in Fatty Liver Disease: Follow-Up of Population Cohorts.

BACKGROUND AND AIMS: The effects of alcohol use in nonalcoholic fatty liver disease are unclear. We investigated the impact of alcohol use in fatty liver disease on incident liver, cardiovascular, and malignant disease, as well as death. APPROACH AND RESULTS: Our study comprised 8,345 persons with hepatic steatosis (fatty liver index >60) who participated in health-examination surveys (FINRISK 1992-2012 or Health 2000), with available data on baseline alcohol intake. Main exclusions were baseline clinical liver disease, viral hepatitis, ethanol intake >50 g/day, and current abstainers. Data were linked with national registers for hospital admissions, malignancies, and death regarding liver, cardiovascular, and malignant disease, as well as all-cause death. Adjustment were for multiple confounders. Alcohol consumption showed a dose-dependent risk increase for incident advanced liver disease and malignancies. Consuming 10-19 g/day of alcohol in general or 0-9 g/day as nonwine beverages doubled the risk for advanced liver disease compared to lifetime abstainers. In contrast, alcohol intake up to 49 g/day was associated with a 22%-40% reduction of incident cardiovascular disease (CVD). We observed a J-shaped association between alcohol intake and all-cause death with a maximal risk reduction of 21% (95% confidence interval, 5%-34%) at alcohol intake of 0-9 g/day compared to lifetime abstainers. However, these benefits on CVD and mortality were only observed in never smokers. Alcohol intake >30 g/day yielded increased risk estimates for mortality compared to lifetime abstainers. In a subpopulation with longitudinal data, alcohol intake remained stable over time in >80% of subjects. CONCLUSIONS: Even low alcohol intake in fatty liver disease is associated with increased risks for advanced liver disease and cancer. Low to moderate alcohol use is associated with reduced mortality and CVD risk but only among never smokers.

Nurse-to-nurse collaboration between nurses caring for older people in hospital and primary health care: A cross-sectional study.

AIMS AND OBJECTIVES: To assess the level of nurse-to-nurse collaboration during the transfer of older people between hospital and primary health care and to evaluate the psychometric properties of the newly developed Nurse-to-Nurse Collaboration Between Sectors Instrument. BACKGROUND: Nurse-to-nurse collaboration is required when older people transfer between hospital and primary health care to enhance the safety and continuity of care to patients. There is a lack of evidence about the nature and level of this collaboration. DESIGN: A cross-sectional survey design was used. This study adhered to the STROBE checklist. METHODS: A sample of 443 nurses (university hospital n = 240, primary health care n = 203) participated in the study from October 2017 to June 2018. Nurses completed the Nurse-to-Nurse Collaboration Between Sectors Instrument (86 items, 7-point Likert-type scale), the Nurse-Nurse Collaboration Scale and the Patient-Centred Competency Scale. RESULTS: Nurses rated the overall level of nurse-to-nurse collaboration moderately high (mean=4.49, standard deviation=0.83, maximum 7.00). Nurses considered collaboration an important and confidential process, gaining older people's trust in their care. Lower scores were given to the agreement of mutual objectives, policies and guidelines in collaboration, opportunities for job rotation and interacting and networking during the collaboration process. The internal consistency reliability of the newly developed instrument was acceptable. CONCLUSIONS: Nurses collaborate with competence and confidentiality during the transfer of older people between care settings. However, there is a need for more opportunities to collaborate, to obtain mutual agreement about objectives, policies and practices, and better understand other nurse's roles and responsibilities in collaboration. The reliability and validity of the Nurse-to-Nurse Collaboration Between Sectors Instrument were acceptable though the number and wording of items will be reviewed and further tested. RELEVANCE TO CLINICAL PRACTICE: Nurses need opportunities to collaborate, and there is a need to develop agreed objectives, practices, roles and responsibilities in this collaboration.

Ethical problems in nursing management: Frequency and difficulty of the problems.

BACKGROUND: Nurse managers (NMs) lead the biggest personnel group in health care-nurses. They have various responsibilities in clarifying an organization's values to their staff and overseeing and supporting continuous upholding of ethical standards and nurses' ethical competence. PURPOSE: The purpose of the study was to investigate the frequency and difficulty of the ethical problems NMs encounter in their work and to determine the background factors correlating with the problems. METHODOLOGY: Cross-sectional survey design was used. Ethical problems were approached by five categories related to patients, nursing staff, other professional groups, the organization, and the NMs themselves. The data collected with questionnaires from NMs in ward, middle, and strategic management (n = 214) in Finland from November 2014 to May 2015 were statistically analyzed. RESULTS: The most frequently encountered ethical problems were related to nursing staff and organization: About half of NMs encountered those problems at least weekly. The most difficult ethical problems were related to the organization-the mean value of the sum score being significantly higher compared to the four other sum scores (p < .0001). When combining information on the frequency and difficulty of the encountered ethical problems, organization-related problems were the most significant. The more positively NMs assessed their work-related background factors, the fewer ethical problems they encountered and the easier they considered them. CONCLUSION: Awareness of the frequency and difficulty of ethical problems in nursing, especially those related to organization, needs to be increased in health care organizations to find solutions for dealing with them. PRACTICE IMPLICATIONS: Strengthening resources for ethics, like ethics experts and multiprofessional committees, may be helpful. Ethical consideration and discussion of prioritization should be routinely used in administrative decision-making. Ethics education and instructions for repetitive situations could increase NMs' ability to manage with ethical problems. Support mechanisms are needed for situations where difficult value clashes appear.

Combined Effects of Alcohol and Metabolic Disorders in Patients With Chronic Liver Disease.

Alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) are the major causes for nonviral liver cirrhosis in the population. Whereas the typical NAFLD patient is one with abdominal obesity, metabolic syndrome (MetS), and no or minimal alcohol use, the patient with pure alcoholic liver cirrhosis has, according to cohort studies, typically consumed >5-10 daily alcohol drinks for several years.1 However, both alcohol use and components of the MetS are continuous variables and, as such, not dichotomic. Recent evidence suggests harmful synergistic effects of obesity, MetS, and alcohol intake for the risk of future liver disease.2 Consequently, given an increasing population prevalence of overweight and obese alcohol users, expectedly, there will be many patients that do not fit either the typical NAFLD or typical ALD phenotype, but share features of both disease entities. Current case-finding strategies focusing on either pure NAFLD or pure ALD3,4 may underestimate the true risk in individuals who will develop liver disease as the result of interaction between alcohol and metabolic disorders.1.

Genetic and lifestyle risk factors for advanced liver disease among men and women.

BACKGROUND AND AIM: Liver disease is traditionally categorized as alcoholic and non-alcoholic. We studied various risk factors predictive of advanced non-viral liver disease in general population and analyzed the interaction between these factors and alcohol consumption. METHODS: Persons without underlying liver disease who participated in the Health2000 or FINRISK studies 1992-2012 comprised a cohort of 41 260 individuals. Pattern of alcohol consumption and metabolic, lifestyle-related, and anthropometric parameters were analyzed with Cox regression analysis using severe liver disease hospitalization, cancer, or death as end-point. Viral liver diseases were excluded. RESULTS: A total of 355 liver events occurred during the mean 12.4-year follow-up (511 789 person-years). In the multivariate model, age (hazard ratio [HR] 1.03, P = 0.0083 for men; HR 1.04, P = 0.0198 for women), waist-to-hip ratio (WHR) (HR 1.52, P = 0.0006 for men; HR 1.58, P = 0.0167 for women), patatin-like phospholipase-containing domain 3 mutations (HR 1.9, P = 0.024 for men; HR 2.7, P = 0.0109 for women), and weekly binge drinking (HR 2.4, P = 0.0024 for men; HR 7.4, P < 0.0001 for women) predicted development of severe liver disease. Among men, diabetes (HR 2.7, P = 0.0002), average alcohol consumption (HR for 10 g/day 1.1, P = 0.0022), non-married status (HR 1.9, P = 0.0397 for single; HR 2.4, P = 0.0002 for widowed/separated), and serum high-density lipoprotein (HR 2.2, P = 0.0022) and non-high-density lipoprotein cholesterol (HR 1.2, P = 0.0237) were additional risk factors. Alcohol intake increased the risk especially among persons with high WHR (P for interaction 0.009). CONCLUSIONS: Age, patatin-like phospholipase-containing domain 3 haplotype, and WHR increase the risk for development of severe liver disease. We found strong synergism between alcohol and central obesity. Binge drinking is an additional risk factor.

Patient education in relation to informational needs and postoperative complications in surgical patients.

OBJECTIVE: To study surgical patients' informational expectations and the level of received knowledge at the time of hospital discharge. To examine if there is an association with postoperative complications and the patient´s level of received knowledge. DESIGN: Comparative descriptive design. SETTING: The data on patients admitted for non-cardiac surgery were collected in three phases during an eight-month period. PARTICIPANTS: 258 in-ward non-cardiac general surgery and orthopedic surgery adult patients. INTERVENTIONS: Questionnaires before admission (knowledge expectations) and at discharge (received knowledge). A telephone interview 30 days after discharge. MAIN OUTCOME MEASURES: Received knowledge (as much or more / less) compared to expectations, and its association with post-discharge complications. RESULTS: There were differences between patient groups in their perception of receiving enough knowledge and they were connected to gender (male vs. female OR 2.67, 95% CI 1.55-4.60, P = 0.0004) and procedure (elective orthopedic implant surgery vs. elective minor orthopedic and hand surgery: OR 3.25, 95% CI 1.72-6.17, P = 0.0003). Patients who received less knowledge than expected had more postoperative complications than those who received sufficient (as much or more than expected) information. CONCLUSIONS: Patients differ in terms of informational needs, and preoperative education prepares the patient for the information provided postoperatively. Patient education may have an influence on recovery from surgery.

Self-evaluated ethical competence of a practicing physiotherapist: a national study in Finland.

BACKGROUND: Patients have the right to equal, respectful treatment. Nowadays, one third of patient complaints concern health care staff's behavior towards patients. Ethically safe care requires ethical competence, which has been addressed as a core competence in physiotherapy. It has been defined in terms of character strength, ethical awareness, moral judgment skills in decision-making, and willingness to do good. The purpose of this study was to analyze the ethical competence of practicing physiotherapists. METHOD: A self-evaluation instrument (Physiotherapist's Ethical Competence Evaluation Tool) based on an analysis of a concept "ethical competence" was constructed in 2016 and physiotherapists (n = 839), working in public health services or private practice responded to the questionnaire. RESULTS: Based on the results, most of the physiotherapists evaluated themselves highly ethically competent in all areas of ethical competence, subscales being Strength, Awareness, Skills and Will. Willingness to do good was evaluated as highest, while character strength, including the strength to support ethical processes and speak on behalf of the patient, was evaluated the lowest. Physiotherapists most commonly consult a colleague when encountering an ethical problem. Other methods for problem solving are not very familiar, neither are the international or national ethical codes of conduct. CONCLUSIONS: This was the first attempt to assess all aspects of ethical competence empirically in a clinical environment in physiotherapy, using a novel self-evaluation instrument. Even if physiotherapists evaluate themselves as competent in ethics, further exploration is needed for ethical awareness. Also the patients' viewpoints about ethically competent care should be considered, to better ensure ethical safety of the patient.

Symptom severity in burning mouth syndrome associates with psychological factors.

Burning mouth syndrome (BMS) patients are psychologically distressed, but whether this associates with symptom severity is unclear. The aim was to investigate the association of psychological factors with pain intensity and interference in BMS. Fifty-two women (mean age 63.1, SD 10.9) with BMS participated. Pain intensity and interference data were collected using 2-week pain diaries. Psychological factors were evaluated using Depression Scale (DEPS), Pain Anxiety Symptom Scale (PASS) and Pain Vigilance and Awareness Questionnaire (PVAQ). The local ethical committee approved the study. Patients were divided into groups based on pain severity distribution tertiles: low intensity (NRS ≤ 3.7) or interference (NRS ≤ 2.9) (tertiles 1-2, n = 35) and moderate to intense intensity (NRS > 3.7) or interference (>2.9) (tertile 3, n = 17). T test, Wilcoxon's test and Pearson's correlation coefficient were used in the analyses. Patients in the highest intensity and interference tertiles reported more depression (P = .0247 and P = .0169) and pain anxiety symptoms (P = .0359 and P = .0293), and were more preoccupied with pain (P = .0004 and P = .0003) than patients in the low intensity and interference groups. The score of the pain vigilance questionnaire correlated significantly with pain intensity (r = .366, P = .009) and interference (r = .482, P = .009). Depression (r = .399, P = .003) and pain anxiety symptoms (r = .452, P = .001) correlated with pain interference. Symptom severity in BMS associates with symptoms of psychological distress emphasising the need to develop multidimensional diagnostics for the assessment of BMS pain.

A pilot study of parents' experiences of reflexology treatment for infants with colic in Finland.

BACKGROUND: Many infants under 4 months suffer from infantile colic. Infants with colic cry a lot, appear to be in pain, and it is difficult to sooth them. Colic is a painful condition for the infant and very stressful to parents. Parents in Finland get advice to try reflexology treatment for their infant, but there are no studies in Finland to support this advice. AIM: The aim of the pilot study was to treat infants with reflexology and find out parents' experiences of the effects of the treatment on colic symptoms and parental stress. METHOD: A total of 33 parents of 35 infants diagnosed with colic participated to the pilot study. Three certified reflexologists with health care education background and extensive experience in infant reflexology were trained to give the reflexology treatment in a standardised manner. They treated each infant 3-4 times. The whole body reflexology treatment session consisted of gentle pressure treatment of soles and feet, hands, head, face, ears, back, neck and whole stomach area. One treatment session lasted about 20-30 minutes, and treatments were delivered within 8-12 days. The data were collected from the parents with semi-structured questionnaires. RESULTS: The series of the treatments helped reduce the suffering of all the babies with infant colic. The colic symptoms disappeared on 43% of infants and decreased on the remaining 57%. The parents reported having pleasant experiences with the treatment, regardless whether the colic symptoms disappeared or continued. Parents stated that the treatment reduced the most typical colic symptoms; infants' body tension, colic crying and restless movements, poor sleep quality and irregular bowel movements. CONCLUSIONS: Reflexology treatment seems to be a safe and effective way to treat infants with colic when conducted by a health care professional with reflexology training and experience.

Relationship between sufficiency and usefulness of patient education: A cross-sectional study of patients with chronic kidney disease.

The aim of this descriptive study was to analyze the relationship between the sufficiency and usefulness of patient education from the perspective of people with chronic kidney disease. The goal was to discover whether both sufficiency and usefulness need to be analyzed in the quality evaluation of patient education. Patients undergoing predialysis or home dialysis care in Finland (N = 162) evaluated both the sufficiency and usefulness of patient education provided by nephrology nurses by using parallel structured questionnaires. A strong relationship was found between the sufficiency and usefulness of patient education. The relationship was significant across all dimensions of empowering knowledge, but no systematic association was found between the sufficiency-usefulness relationship and background variables. Depending on the purpose of evaluating patient education, either aspect, that is, sufficiency or usefulness, can be used, but it is not necessary to use both due to their strong inter-correlation. In terms of implications for practice, consideration of both sufficiency and usefulness is important when providing empowering patient education for people undergoing pre- or home dialysis, but only one aspect needs to be evaluated.

Interaction between alcohol consumption and metabolic syndrome in predicting severe liver disease in the general population.

The metabolic syndrome and alcohol risk use are both associated with a high prevalence of hepatic steatosis, but only a minority develop liver failure or liver cancer. Few general population studies have analyzed metabolic predictors of such severe liver complications. We studied which metabolic factors best predict severe liver complications, stratified by alcohol consumption, in 6732 individuals without baseline liver disease who participated in the Finnish population-based Health 2000 Study (2000-2001), a nationally representative cohort. Follow-up data from national registers until 2013 were analyzed for liver-related admissions, mortality, and liver cancer. Baseline alcohol use and metabolic factors were analyzed by backward stepwise Cox regression analysis. Eighty-four subjects experienced a severe liver event during follow-up. In the final multivariate model, factors predictive of liver events were age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.004-1.04), sex (women: HR, 0.55; 95% CI, 0.34-0.91), alcohol use (HR, 1.002; 95% CI, 1.001-1.002), diabetes (HR, 2.73; 95% CI, 1.55-4.81), low-density lipoprotein (LDL) cholesterol (HR, 0.74; 95% CI, 0.58-0.93), and homeostasis model assessment of insulin resistance (HOMA-IR) (HR, 1.01; 95% CI, 1.004-1.02). Among alcohol risk users (≥210 g/week for men, ≥ 140 g/week for women), diabetes (HR, 6.79; 95% CI, 3.18-14.5) was the only significant predictor. Among nonrisk drinkers, age, alcohol use, smoking, waist circumference, low LDL cholesterol and HOMA-IR were significant independent predictors. The total-to-LDL cholesterol ratio and waist circumference-to-body mass index ratio emerged as additional independent predictors. CONCLUSION: Multiple components of the metabolic syndrome independently affected the risk for severe liver disease. Alcohol was significant even when average alcohol consumption was within the limits currently defining nonalcoholic fatty liver disease. (Hepatology 2018;67:2141-2149).

Periodontitis is associated with incident chronic liver disease-A population-based cohort study.

BACKGROUND & AIMS: Chronic liver disease is a major health concern worldwide and the identification of novel modifiable risk factors may benefit subjects at risk. Few studies have analyzed periodontitis as a risk factor for liver complications. We studied whether periodontitis is associated with incident severe liver disease. METHODS: The study comprised 6165 individuals without baseline liver disease who participated in the Finnish population-based Health 2000 Survey (BRIF8901) during 2000-2001, a nationally representative cohort. Follow-up was until 2013 for liver-related admissions, liver cancer and mortality from National Hospital Discharge, Finnish Cancer Registry and Causes of Death Register, Statistics Finland. Mild to moderate periodontitis was defined as ≥1 tooth with periodontal pocket ≥4 mm deep, and advanced periodontitis as ≥5 teeth with such pockets. Multiple confounders were considered. RESULTS: A total of 79 subjects experienced a severe liver event during follow-up. When adjusted for age, sex and number of teeth, hazards ratios by Cox regression regarding incident severe liver disease were, for mild to moderate periodontitis, 2.12 (95% CI 0.98-4.58), and, for advanced periodontitis, 3.69 (95% CI 1.79-7.60). These risk estimates remained stable after additionally adjusting for alcohol use, smoking, metabolic risk, serum gamma-glutamyltransferase, dental-care habits, lifestyle and socioeconomic status. Periodontal disease-associated liver risk was accentuated among subjects with non-alcoholic fatty liver disease or heavy alcohol use at baseline. CONCLUSIONS: Periodontitis was associated with incident liver disease in the general population independently of various confounders. As a preventable disease, periodontal disease might present a modifiable risk factor for chronic liver disease.

Ethical problems in nursing management - a cross-sectional survey about solving problems.

BACKGROUND: Nurse managers encounter a wide range of ethical problems related to patients, staff, the organisation and themselves. However, little is known about the methods they use to try to solve these problems. In this study, our goal is to fill this knowledge gap by investigating the ethical problems encountered by nurse managers, the frequency of use and usefulness of different methods to solve these problems, and the background factors associated with the use of the methods. METHODS: A cross-sectional survey study was conducted in November 2014-May 2015 in Finland. The data were collected from nurse managers in strategic, middle and ward management (n = 214) using a questionnaire developed for this study. The questionnaire consisted of four parts: socio-demographic background factors, frequency and difficulty of ethical problems in nursing management, frequency of use and usefulness of the methods in solving ethical problems, and work-related background factors. RESULTS: Discussions with nurses was the most frequently used method, used by 94% of the nurse managers either often or always in the case of ethical problems, followed by the use of personal values (74%) and discussions with manager colleagues (70%). However, almost all methods in the different groups - discussion and deliberation, use of outside experts, written instructions and ethical principles, acts and degrees as well as work arrangements - were considered somewhat or very useful by more than half of the respondents. The use of outside experts was the least used and the least useful method. CONCLUSIONS: When solving ethical problems, nurse managers use most frequently the same methods as a few decades ago. A more diverse range of methods would be helpful in ethical problem-solving. The use of outside experts, ethics literature and codes of ethics should be combined with ethical reasoning and decision-making to get new dimensions and outside knowledge.

Local treatment of pressure ulcers in long-term care: a correlational cross-sectional study.

OBJECTIVE: To analyse the treatment of pressure ulcers (PU) in long-term care. METHOD: In this correlational cross-sectional study, data was collected between November 2015 and January 2016 from older people with PUs in private and public long-term care facilities in Finland. Data collection was conducted by trained nurses using the Pressure Ulcer Patient Instrument (PUP-Ins). Outcomes measured were: prevalence and localisation of PU, local PU treatment, frequency (how often/week/day) and duration (minutes/week or day) of PU treatment. RESULTS: In total, 112 patients with 158 PUs were identified (a prevalence rate of 5%). PUs were located most often on the heel (38%), hip (13%), buttocks (10%) and lateral malleolus (9.5%). The most frequently used PU treatment was skin protecting agents and local wound care products. The most typical treatment in category I, II and III PUs were foam dressings. In category III PUs, ribbon gauze dressings were also used. The most typical products for category IV PUs were complex dressings. Category I PUs received more treatment per day or week than other categories of PUs. CONCLUSION: PU treatment is inconsistent and often conducted with varying methods and products. Holistic patient care must be the focus. Nurses in long-term care settings might benefit from in-depth in-service education focusing on the treatment of PUs. More research is needed about nurses' competence in PU treatment.

Graduating student nurses' and student podiatrists' wound care competence: a cross-sectional study.

OBJECTIVE: To explore and describe graduating student nurses' (SNs) and student podiatrists' (SPs) theoretical wound care competence, as well as students' own perceptions of their wound care competence and their opinions about the received wound care education. METHOD: A descriptive cross-sectional design was used. Data were collected from five Finnish universities using a graduating SNs and SPs wound care competence (WCC) questionnaire, which included a wound care knowledge test and a wound care competence self-evaluation. Data were analysed statistically and with qualitative content analysis. RESULTS: A total of 213 students (response rate: 86%) participated in the study. Of these, 194 were SNs and 19 SPs. Students answered 48% of the knowledge test questions correctly (SNs 46%, total score 14/29; SPs 60%, total score 13/22). SPs' wound care competence was statistically significantly higher (p<0.0001) than that of SNs. Both groups self-evaluated their wound care competence to be deficient. Students who had more practical training in wound care during practical training periods scored statistically significantly better in the knowledge test. Students showed a positive attitude towards wound care by expressing an interest in it and acknowledging its importance. CONCLUSION: Graduating SNs' and SPs' theoretical wound care competence is limited. The results showed that more wound care education, especially practical training, is needed in SNs' and SPs' education curriculums to adequately respond to the increasing needs in wound care.