Increased risk of active tuberculosis during pregnancy and postpartum: a register-based cohort study in Sweden.

RATIONALE: Studies investigating the risk of active tuberculosis (TB) in association with pregnancy have not been conclusive. We aimed to investigate this risk in a large retrospective register-based cohort study in Sweden. METHODS: Data from women of 15-49 years of age who had given birth in Sweden between 2005 and 2013 were extracted from the national childbirth register and linked to the national TB register. Cohort time was divided into three exposure periods: during pregnancy, six months (180 days) postpartum and time neither pregnant nor postpartum. We calculated incidence rates (IRs) per 100 000 person-years for each period and incidence rate ratios (IRRs) with IRs neither pregnant nor postpartum as the reference. RESULTS: The cohort included 649 342 women, of whom 553 were registered as cases of active TB, 389 when neither pregnant nor postpartum, 85 during pregnancy and 79 when postpartum. Overall IRs were 9, 12 and 17 cases per 100 000 person-years, respectively, giving IRR 1.4, 95% CI 1.1-1.7 (during pregnancy) and IRR 1.9, 95% CI 1.5-2.5 (when postpartum). Stratification by TB incidence in country of origin showed that the increased risk was concentrated amongst women from countries with a TB incidence of 100 or higher, where IRs per 100 000 person-years were 137 (when neither pregnant nor postpartum), 182 (during pregnancy) and 233 (when postpartum). CONCLUSION: We show a significant increase in risk of active TB during both pregnancy and postpartum in women from high incidence countries and recommend TB screening in pregnant women belonging to this risk group.

Screening and treatment of tuberculosis among pregnant women in Stockholm, Sweden, 2016-2017.

Swedish National tuberculosis (TB) guidelines recommend screening of active and latent TB (LTBI) among pregnant women (PW) from high-endemic countries or with previous exposure to possibly improve early detection and treatment.We evaluated cascade of care of a newly introduced TB screening programme of pregnant women in Stockholm county in 2016-2017. The algorithm included clinical data and Quantiferon (QFT) at the Maternal Health Care clinics and referral for specialist care upon positive test or TB symptoms.About 29 000 HIV-negative pregnant women were registered yearly, of whom 11% originated from high-endemic countries. In 2016, 72% of these were screened with QFT, of which 22% were QFT positive and 85% were referred for specialist care. In 2017, corresponding figures were 64%, 19% and 96%, respectively. The LTBI treatment rate among all QFT-positive pregnant women increased from 24% to 37% over time. Treatment completion with mainly rifampicin post-partum was 94%. Of the 69 registered HIV-positive pregnant women, 78% originated from high-endemic countries. Of these, 72% where screened with QFT and 15% were positive, but none was treated for LTBI. 9 HIV-negative active pulmonary TB cases were detected (incidence: 215/100 000). None had been screened for TB prior to pregnancy and only one had sought care due to symptoms.Systematic TB screening of pregnant women in Stockholm was feasible with a high yield of unknown LTBI and mostly asymptomatic active TB. Optimised routines improved referrals to specialist care. Treatment completion of LTBI was very high. Our findings justify TB screening of this risk group for early detection and treatment.

Diagnostic pathways and delay among tuberculosis patients in Stockholm, Sweden: a retrospective observational study.

BACKGROUND: Asylum seekers in Sweden are offered tuberculosis (TB) screening at a voluntary post-arrival health examination. The role of this screening in improving the TB diagnostic pathway has not been previously evaluated. The aim of this study was to determine diagnostic pathways for active TB cases and compare diagnostic delays between different pathways. METHODS: Retrospective review of medical records of patients reported with active TB in Stockholm in 2015, using a structured and pre-coded form. RESULTS: Seventy-one percent of patients actively sought health care due to symptoms. As for source of referral to TB specialist clinic, 15% came from screening of eligible migrants, of whom the majority were asymptomatic. Among asylum seekers, 69% were identified through screening at a health examination (HE). The main sources of referral to TB clinics were emergency departments (27%) and primary health care centers (20%). Median health care provider delay was significantly longer in patients identified through migrant screening in health examination. CONCLUSIONS: Screening at a health examination was the main pathway of active TB detection among mainly asymptomatic and non-contagious asylum seekers but contributed modestly to total overall TB case detection. In these patients TB was diagnosed early in a non-contagious phase of the disease. Further research is required to assess the effectiveness and cost-effectiveness of HE TB screening as well as inclusion of other groups of migrants from high incidence countries in the screening program in terms of impact on delay, transmission and treatment outcomes.

A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and teamwork in maternity care.

AIM: The aim of this study was to explore healthcare professionals' (HCPs) perceptions of adverse events (AE) during childbirth with focus on communication and teamwork. BACKGROUND: Inadequate communication, a poor teamwork climate and insufficient team training are harmful to women. Reviews of reported AE can be used to develop a safety culture based on preparedness for preventing AE and strengthening patient safety (PS). DESIGN: Action research principles were used to facilitate the implementation and evaluation of this study. METHODS: An interprofessional team of HCPs comprising obstetricians, registered midwives and assistant nurses employed at a labour ward agreed to take part. Data were collected from multistage focus group interviews (March 2016-June 2016) and analysed by means of interpretative thematic analysis. FINDINGS: Two analytical themes based on five sub-themes emerged; promoting interprofessional teamwork and building capabilities by involving HCPs and elucidating relevant strategies. The findings reveal the importance of facilitating relationships based on trust and respectful communication to ensure a safe environment and provide safe maternity care. CONCLUSION: There is a need for formal and informal support for quality interprofessional teamwork. Research on PS may reduce AE related to miscommunication and poor teamwork. We recommend different forms of communication and teamwork training in interprofessional teams to increase the ability to provide feedback. Accumulated research is required for the evaluation of evidence-based models in the PS context.

Risk management-Evaluation of healthcare professionals' reasoning about and understanding of maternity care.

AIM: To evaluate healthcare professionals' explanations of the prerequisites for safe maternity care and understanding of risk management, including the underlying reasons for decision-making intended to ensure safe care. BACKGROUND: Risk management focuses on maintaining and promoting safe care by identifying circumstances that place childbearing women at risk of harm, thus reducing risks. METHODS: A hermeneutic action research approach was chosen. Through a series of focus group sessions, we uncovered healthcare professionals' explanations of risk management. RESULTS: One overriding theme emerged; the consequences of what managers do or fail to do constitute the meaning of taking responsibility for team collaboration to provide safe care. Inadequate support, resources and staff shortages have consequences, such as inability to concentrate on team communication and collaboration, leading to the risk of unsafe care. CONCLUSION: Communication constitutes a prerequisite for both team collaboration and risk management. Thus, communication is linked to the ability of managers and healthcare professionals to provide safe care. IMPLICATIONS FOR NURSING MANAGEMENT: In terms of safety management, nurse managers have a significant role in and responsibility for supporting communication training, developing guidelines and providing the prerequisites for interprofessional team reflection.

Qualitative study of women's experiences of safe childbirth in maternity care.

Few studies have focused on women's childbirth experiences in relation to patient safety. The aim of this study was to explore the meaning of safety as a process phenomenon by outlining women's positive and negative experiences of safety in childbirth. A descriptive explorative design was chosen and 16 interviews were conducted. Qualitative content analysis was used. One main theme emerged: safe childbirth through involvement and guidance, based on four subthemes. The characteristics of women's experiences of safe childbirth included the need to be informed and involved by sharing and receiving trustworthy information. Women's experiences of unsafe childbirth included lack of meaningful and trustworthy information that resulted in feelings of being misled or lulled into a false sense of security. Not being involved evoked feelings of being ignored. In conclusion, this study highlights issues of importance for safe maternity care. The perspectives of childbearing women can contribute to an understanding of how to achieve meaningful improvements to provide safer maternity care.

A phenomenological study of living with a partner affected with dementia.

INTRODUCTION: Caring for people affected by dementia is a collective effort that involves public health, primary care, and informal care. The third mainly comprises the efforts of spouses. AIM: This study aimed to describe spouses' experiences of living with a partner affected with dementia. METHOD: The study has a descriptive phenomenological approach based on a reflective life-world perspective. Seven in-depth interviews were conducted with spouses of persons affected with dementia. The interviews were audiotaped and analysed using the procedures described by Giorgi (2009) . FINDINGS: The essence of living with a partner affected by dementia formed a comprehensive theme: from togetherness to loneliness, which along with three descriptive categories-changes in their partner's behaviour, changes in everyday life, and a changed future-describes the phenomenon. CONCLUSION: The theme 'From togetherness to loneliness' reflects the spouses' descriptions of their life-world. Daily life changed gradually in line with their partners' personality, and their role became that of a care provider rather than a spouse. Information and knowledge about dementia should be provided at an early stage. Health care has a major responsibility to meet their needs, thus ensuring that all parties are satisfied.

Nurse collaboration in community and psychiatric care: a Swedish study.

AIM: The aim of the study was to examine registered nurses' (RNs) experiences of collaboration in the community health care and psychiatric inpatient care systems. BACKGROUND: RNs in one area in the west of Sweden have indicated the need for collaborative routines between the community health care and psychiatric inpatient care systems. METHOD: Qualitative content analysis of focus group interviews. RESULTS: RNs felt the web-based health-care communication programme was a major obstacle to the development of a collaboration plan. The poor collaboration between RNs was due to the absence of knowledge about the duties of each nursing team. CONCLUSION: The findings contribute to the understanding of the barriers to collaboration between RNs in community health care and psychiatric inpatient care, and highlight the need for nurse managers to ensure well-functioning routines.

Tuberculosis among HIV-infected patients in Stockholm, Sweden, 1987-2010: treatment outcomes and adverse reactions.

BACKGROUND: The treatment of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) is challenging. The aim of this study was to compare socio-demographic and clinical characteristics among HIV-infected patients before and after the introduction of combined antiretroviral therapy (cART) in a Swedish cohort, and to identify factors associated with anti-TB treatment success as well as adverse reactions. METHODS: This was a retrospective observational study of HIV/TB co-infected patients in Stockholm County from 1987 to 2010. The study population was stratified into an early and a late cohort (before and after the introduction of cART in 1996). Data were analyzed using descriptive statistics and multiple logistic regression analysis. RESULTS: The study population comprised 127 patients; the majority were foreign-born (87%). The proportion of female patients more than doubled from the early to the late cohort, and anti-TB treatment success increased from 65% to 91%. The median duration of successful treatment was 8 months in both cohorts. Predictors of treatment success in the late cohort were cART (odds ratio (OR) 13.3, 95% confidence interval (CI) 1.5-114.8) and a CD4 cell count at TB diagnosis > 200 cells/µl (OR 17.2, 95% CI 1.2-236.6). Severe adverse reactions in the late cohort occurred in 23% and were associated with the initiation of cART after TB diagnosis (OR 13.3, 95% CI 1.6-112.4). CONCLUSION: The introduction of cART was favourable for the treatment outcome of HIV-infected patients with concomitant TB. However, adverse reactions increased in patients who initiated cART during anti-TB treatment and these patients require careful attention.

Risk of HIV transmission from patients on antiretroviral therapy: a position statement from the Public Health Agency of Sweden and the Swedish Reference Group for Antiviral Therapy.

The modern medical treatment of HIV with antiretroviral therapy (ART) has drastically reduced the morbidity and mortality in patients infected with this virus. ART has also been shown to reduce the transmission risk from individual patients as well as the spread of the infection at the population level. This position statement from the Public Health Agency of Sweden and the Swedish Reference Group for Antiviral Therapy is based on a workshop organized in the fall of 2012. It summarizes the latest research and knowledge on the risk of HIV transmission from patients on ART, with a focus on the risk of sexual transmission. The risk of transmission via shared injection equipment among intravenous drug users is also examined, as is the risk of mother-to-child transmission. Based on current knowledge, the risk of transmission through vaginal or anal intercourse involving the use of a condom has been judged to be minimal, provided that the person infected with HIV fulfils the criteria for effective ART. This probably also applies to unprotected intercourse, provided that no other sexually transmitted infections are present, although it is not currently possible to fully support this conclusion with direct scientific evidence. ART is judged to markedly reduce the risk of blood-borne transmission between people who share injection equipment. Finally, the risk of transmission from mother to child is very low, provided that ART is started well in advance of delivery.

Community nurses' experiences of ethical problems in end-of-life care in the patient's own home.

AIM: To gain a deeper understanding of community nurses' experiences of ethical problems in end-of-life care in the patient's own home. METHOD: Ten female nurses from five different communities with experience of end-of-life care were interviewed. A hermeneutic approach inspired by Gadamer was used to analyse the qualitative data from the interviews. FINDINGS: In the first step of interpretation, two themes emerged: Uncomfortable feelings and Lack of cooperation and in the second step, one theme Lack of security emerged. Finally, the overall interpretation revealed the theme Feelings of loss of control in end-of-life care in the patient's own home. CONCLUSION: The nurses exhibited commitment and a desire to do good when caring for patients in the end-of-life phase, even if they sometimes experienced feelings of lack of control. This implies that, when confronted with care-related issues, they have the power to both act and react. This study aimed to increase understanding of ethical problems that arise in end-of-life care in the patient's own home and revealed the need to take the patients', relatives' and nurses' perspectives on health and suffering into consideration to ensure good end-of-life home care.

Older persons' lived experiences of depression and self-management.

Mental ill-health, such as depression in the elderly, is a complex issue that is influenced by the life-world perspective of older persons. Their self-management ability should be strengthened based on an understanding of their situation, perspectives, and vulnerability. The aim of this study was to explore and increase understanding of old persons' lived experiences of depression and self-management using an interpretative explorative design. Understanding was developed by means of hermeneutic interpretation. One theme, Relationships and Togetherness, and four subthemes, A Sense of Carrying a Shoulder Bag, Walking on Eggshells, Holding the Reins, and Estrangement--a Loss of Togetherness, emerged. A collaborative approach can be important for empowering older persons through self-development and management. Although the findings of the present study cannot be considered conclusive or definitive, they nevertheless contribute new knowledge of older persons' lived experiences of depression in everyday life.

Dynamics of two separate but linked HIV-1 CRF01_AE outbreaks among injection drug users in Stockholm, Sweden, and Helsinki, Finland.

Detailed phylogenetic analyses were performed to characterize an HIV-1 outbreak among injection drug users (IDUs) in Stockholm, Sweden, in 2006. This study investigated the source and dynamics of HIV-1 spread during the outbreak as well as associated demographic and clinical factors. Seventy Swedish IDUs diagnosed during 2004 to 2007 were studied. Demographic, clinical, and laboratory data were collected, and the V3 region of the HIV-1 envelope gene was sequenced to allow detailed phylogenetic analyses. The results showed that the Stockholm outbreak was caused by a CRF01_AE variant imported from Helsinki, Finland, around 2003, which was quiescent until the outbreak started in 2006. Local Swedish subtype B variants continued to spread at a lower rate. The number of new CRF01_AE cases over a rooted phylogenetic tree accurately reflected the transmission dynamics and showed a temporary increase, by a factor of 12, in HIV incidence during the outbreak. Virus levels were similar in CRF01_AE and subtype B infections, arguing against differences in contagiousness. Similarly, there were no major differences in other baseline characteristics. Instead, the outbreak in Stockholm (and Helsinki) was best explained by an introduction of HIV into a standing network of previously uninfected IDUs. The combination of phylogenetics and epidemiological data creates a powerful tool for investigating outbreaks of HIV and other infectious diseases that could improve surveillance and prevention.

Nursing students' perspectives on the patient and the impact of the nursing culture: a meta-synthesis.

AIM: To explore and interpret how nursing students develop their understanding of the patient as a human being. BACKGROUND: Understanding the patient is the main characteristic of good, caring performance. In addition, nurse leaders play an active role in creating a culture in which nursing students can flourish and improve. METHOD: This meta-synthesis was based on Noblit and Hare's meta-ethnography. RESULTS: The overarching metaphor was interpreted as the nursing students' capacity for compassion. Two central metaphors were revealed, based on how nursing students developed their understanding of the patient as a human being. These central metaphors were labelled 'The open door', comprising seven key metaphors and 'The closed door' based on two key metaphors. CONCLUSION: During practical training, the students observed both virtuous and unkind nurses. Virtue is a skill that can be taught, but not all students were able to learn it. Some students acquired the ability to reflect on ethical issues, while others did not. Therefore, good role models are of major importance. IMPLICATION FOR NURSING MANAGEMENT: The nurse leader should function as a facilitator in the students' efforts to gain the capacity to face the suffering patient and to develop an understanding of the patient's situation.

A quality registers impact on community nurses' in end-of-life care - a grounded theory study.

AIM: The aim of the study was to identify the impact of a quality register in end-of-life-care, from community nurses' perspective. BACKGROUND: There is a lack of knowledge about the impact of such a register in end-of-life care. METHOD: Data were collected by means of focus group interviews with a total of 12 nurses, from two communities in the western part of Sweden. Data analysis was based on grounded theory. RESULT: Feedback is the core category that influences all other processes. Two main categories emerged: 'Becoming aware of' and 'Acting accordingly'. These influenced the nurses and led to improved quality of care. CONCLUSION: A quality register gives the users (nurses) feedback on the care provided, which starts a process of change. IMPLICATIONS FOR NURSING MANAGEMENT: The value of working with a quality register as a feedback system can be applicable to all professions working with quality assurance. The experiences will increase the motivation and understanding the value of using quality registers as a tool for enhanced quality. Further, nurse managers can use such a register as a feedback system, not only as a motivating tool when implementing a quality register, but in the evaluation of its outcomes.

Effectiveness of an adjuvanted monovalent vaccine against the 2009 pandemic strain of influenza A(H1N1)v, in Stockholm County, Sweden.

BACKGROUND: Vaccination against the pandemic influenza A(H1N1)v was performed in many countries during 2009, but population-based data on vaccine effectiveness are lacking. METHODS: We conducted a prospective cohort study involving all inhabitants in Stockholm County (n = 2,019,183) who were offered a monovalent AS03-adjuvanted influenza A(H1N1)v vaccine (Pandemrix, GSK), between 12 October and 31 December 2009. Overall vaccine coverage was 52%. A Web-based register with data on all vaccinated was linked by unique personal identification number to mandatory reports of influenza A(H1N1)v diagnoses. Vaccine failure was defined as a diagnosis or admission to hospital because of influenza >14 days after vaccination. Risk factors associated with vaccine failure were investigated by conditional stepwise logistic regression in a nested case-control study. The weekly incidence rate ratio for being diagnosed with influenza among vaccinated versus nonvaccinated persons was calculated. RESULTS: Vaccine failure was seen in 25 patients, 11 children and 14 adults, of 2594 patients diagnosed with influenza A(H1N1)v. Compared with age-matched controls, patients with vaccine failure were more often immunocompromised (Hazard Ratio, 4.89; 95% confidence interval [CI], 2.19-10.89). During the 4 weeks with maximum influenza activity, the relative risk per week for an influenza A(H1N1)v diagnosis in the vaccinated population was .06 (95% CI .008-.41), .13 (95% CI .06-.27), .05 (95% CI .02-.12), and .07 (95% CI .03-.15), respectively, corresponding to a weekly vaccine effectiveness of 87-95%. CONCLUSIONS: The monovalent AS03-adjuvanted influenza vaccine was highly effective in prevention of the pandemic influenza in Stockholm County. A single dose seemed to be sufficient in most, both children and adults, except in immunocompromised hosts.

Dignified end-of-life care in the patients' own homes.

Nowadays it is increasingly common that the patients in the end of life phase choose to be cared for in their own home. Therefore it is vital to identify significant factors in order to prevent unnecessary suffering for dying patients and their families in end-of-life homecare. This study aimed to describe 10 nurses' perceptions of significant factors that contribute to good end-of-life care in the patients own home. The transcribed texts from the interviews' were analyzed using phenomenological hermeneutical method, which focuses on the life-world of human beings. The results demonstrate that good end-of-life care presupposes that the aim of the caring staff is to provide safety, autonomy and integrity for the patient and family in order to create the respect required for as good and dignified a death as possible.

Community nurses' experiences of ethical dilemmas in palliative care: a Swedish study.

AIM: The aim of this study was to highlight community nurses' experiences of ethical dilemmas in palliative care. BACKGROUND: There are many studies on palliative care but research on how community nurses experience ethical dilemmas in palliative home care is lacking. The ethical dilemmas to which these nurses are exposed seriously challenge their ethical competence. METHOD: Seven community nurses described their experiences of ethical dilemmas in palliative home care. The data was analysed by means of qualitative content analysis. FINDINGS: The core themes that emerged were: powerlessness, frustration, and concern in relation to ethical dilemmas in palliative care. The nurses were motivated and felt responsibility for their patients' end of life, and their relatives, and took their duties seriously. They wanted to satisfy all parties; the patient, the relatives and other palliative care professionals. CONCLUSION: The study confirms the need for knowledge about how community nurses experience dilemmas in ethical decision-making. They have the freedom to act and the willingness to make decisions, but they lack competence and knowledge about how their colleagues' experience and deal with such issues.

Diabetes empowerment related to Pender's Health Promotion Model: a meta-synthesis.

Diabetes self-management is a challenge for both clients and health-care professionals. Empowerment plays a vital role in helping clients to achieve successful self-management. This study adopted a meta-ethnographic approach. Nine qualitative studies were synthesized in order to contribute to a deeper understanding of what clients perceive as being important in an effective empowerment strategy for diabetes self-management. Four central metaphors that influenced empowerment were identified: trust in nurses' competence and awareness, striving for control, a desire to share experiences, and nurses' attitudes and ability to personalize. The lines-of-argument synthesis suggested the need for an evaluation system to appraise clients' diabetes knowledge, health beliefs, and negative emotions, as well as the outcome of interventions. Based on Pender's Health Promotion Model, this study emphasizes the fact that health-care professionals need to understand and address modifiable behavior-specific variables. The study suggests that an effective empowerment strategy would be to use activity-related affect, as well as interpersonal and situational influences, as a means of facilitating and enhancing clients' health-promoting behaviors.

Decision making within a community provider organization.

AIM: To explore community nurses' experiences of decision making within the community provider organization. BACKGROUND: Recent changes in health care with an increasing number of patients being cared for outside of institutions can put considerable pressure on the nurse with respect to decision making. METHODS: In-depth interviews were performed with 6 registered nurses in two communities. The interviews were analysed by means of phenomenological hermeneutics. RESULTS: The community nurses' experiences of decision making were interpreted as spiders or octopuses, consultants and troubleshooters. The subthemes were; networking and structuring, responsibility, availability and knowledge, assessment power, information selection, avoiding rules and bypassing managers. In accordance with hermeneutical phenomenology, the findings were discussed and explained with reference to Ofstad's philosophy of freedom to make decisions. CONCLUSION: In their decision making, community nurses are committed to finding administrative solutions that satisfy patient needs.