Translation and Validation of the Self-Assessment Psoriasis Area Severity Index.

BACKGROUND: The self-assessment psoriasis area severity index (SAPASI) is a patient-administered psoriasis assessment tool for which we present a validated translation from English to Swedish. METHODS: Validity was evaluated in this single-centre study using the psoriasis area severity index (PASI) as the standard. Test-retest reliability was assessed using repeated SAPASI measurements. RESULTS: Significant correlations (p < 0.0001) using Spearman's correlation coefficient (r) were found between PASI and SAPASI scores (r = 0.60) for 51 participants (median baseline PASI 4.4, interquartile range [IQR]: 1.8-5.6) and repeated SAPASI measurements (r = 0.70) among 38 participants (median baseline SAPASI 4.0, IQR: 2.5-6.1). Bland-Altman plots showed generally higher SAPASI scores than PASI scores. CONCLUSION: The translated version of SAPASI is valid and reliable, although patients generally tend to overrate their disease severity compared to PASI. Keeping this limitation in mind, SAPASI has the potential of being implemented as a time- and cost-efficient assessment tool in a Scandinavian context.

Impact of Bariatric Surgery on Moderate to Severe Psoriasis: A Retrospective Nationwide Registry Study.

Studies of the effects of bariatric surgery on psoriasis are few, with conflicting results. By linking the Swedish National Register for Systemic Treatment of Psoriasis (PsoReg) with the Scandinavian Obesity Surgery Registry (SOReg), individuals with psoriasis who had undergone bariatric surgery in Sweden during 2008 to 2018 were identified, and matched with data for patients with psoriasis in PsoReg. Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were compared between the groups. Altogether, 50 operated individuals (median body mass index (BMI) 38.7 kg/m2]) and 91 non-operated individuals (median BMI 33.0 kg/m2) were included. Control of disease at baseline was good in both groups. Linear mixed models showed no significant difference in psoriasis disease burden, measured as changes in mean PASI (ΔPASI) (-1.2, p = 0.43) and DLQI (ΔDLQI) (-2.2, p = 0.34). In summary, this study demonstrated no significant effect of bariatric surgery on psoriasis disease burden in patients with relatively well-controlled moderate to severe psoriasis.

Cardiorespiratory fitness in late adolescence and long-term risk of psoriasis and psoriatic arthritis among Swedish men.

BACKGROUND: Psoriasis is a chronic immune-mediated disease and psoriatic arthritis is a common coexisting condition. Cardiorespiratory fitness is the overall capacity to perform exertion exercise. Low levels of cardiorespiratory fitness are associated with negative health outcomes. Individuals with psoriasis have lower cardiorespiratory fitness compared with individuals without psoriasis. There are no previous studies exploring the association between cardiorespiratory fitness and new-onset psoriasis and psoriatic arthritis. METHODS: With the objective to investigate whether low cardiorespiratory fitness in late adolescence increases the risk for onset of psoriasis and psoriatic arthritis, a cohort of Swedish men in compulsory military service between 1968 and 2005 was created using data from the Swedish Military Service Conscription Register. Cardiorespiratory fitness, estimated by maximum capacity cycle ergometer testing at conscription, was divided into three groups: high, medium, and low. Diagnoses were obtained using the Swedish National Patient Register and cohort members were followed from conscription until an event, new-onset psoriasis or psoriatic arthritis, occurred, or at the latest until 31 December 2016. Cox regression models adjusted for confounders at conscription were used to obtain hazard ratios with 95% confidence intervals for incident psoriasis and psoriatic arthritis. RESULTS: During the follow-up period (median follow-up time 31 years, range 0-48 years), 20,679 cases of incident psoriasis and 6,133 cases of incident psoriatic arthritis were found among 1,228,562 men (mean age at baseline 18.3 years). There was a significant association between low cardiorespiratory fitness and incident psoriasis and psoriatic arthritis (hazard ratio 1.35 (95% confidence interval 1.26-1.44) and 1.44 (95% confidence interval 1.28-1.63), respectively). CONCLUSIONS: These novel findings suggest that low cardiorespiratory fitness at an early age is associated with increased risk of incident psoriasis and psoriatic arthritis among men, and highlight the importance of assessing cardiorespiratory fitness early in life.

[A case of quetiapine-induced congenital thrombotic thrombocytopenic purpura, atypical phenotype diagnosed in adulthood]. / Kongenital trombotisk trombocytopen purpura ­ ett fall med atypisk bild upptäckt i vuxen ålder.

Congenital thrombocytopenic purpura (TTP) is a rare but serious condition. We present a case of a 29-year-old woman, diagnosed with this disease in adulthood. The episode that led to diagnosis was triggered by quetiapine. She presented with neurological symptoms and laboratory findings including low platelets and elevated creatinine. Interestingly, the signs of hemolysis were very subtle. Her symptoms were relieved by withdrawal of the medicine. The diagnosis was confirmed by very low ADAMTS13 activity, lack of antibodies against ADAMTS13 and the presence of a compound heterozygous ADAMTS13 mutation. Despite prophylactic plasma infusions, the patient developed a second episode of microangiopathy, leading to an extensive cerebral infarction. It is possible that even the latter episode was triggered by drugs. We suggest that the diagnosis of TTP should be considered in patients with neurological symptoms and unexplained thrombocytopenia.

Bestrophin-3 Expression in a Subpopulation of Astrocytes in the Neonatal Brain After Hypoxic-Ischemic Injury.

Bestrophin-3, a potential candidate for a calcium-activated chloride channel, recently was suggested to have cell-protective functions. We studied the expression and alternative splicing of bestrophin-3 in neonatal mouse brain and after hypoxic-ischemic (HI) injury and in human neonatal brain samples. HI brain injury was induced in 9-day old mice by unilateral permanent common carotid artery occlusion in combination with exposure to 10% oxygen for 50 min. Endoplasmic reticulum stress was induced by thapsigargin treatment in primary culture of mouse brain astrocytes. We also investigated expression of bestrophin-3 protein in a sample of human neonatal brain tissue. Bestrophin-3 protein expression was detected with immunohistochemical methods and western blot; mRNA expression and splicing were analyzed by RT-PCR. HI induced a brain tissue infarct and a pronounced increase in the endoplasmic reticulum-associated marker CHOP. Three days after HI a population of astrocytes co-expressed bestrophin-3 and nestin in a penumbra-like area of the injured hemisphere. However, total levels of Bestrophin-3 protein in mouse cortex were reduced after injury. Mouse astrocytes in primary culture also expressed bestrophin-3 protein, the amount of which was reduced by endoplasmic reticulum stress. Bestrophin-3 protein was detected in astrocytes in the hippocampal region of the human neonatal brain which had patchy white matter gliosis and neuronal loss in the Sommer's sector of the Ammon's horn (CA1). Analysis of bestrophin-3 mRNA in mouse brain with and without injury showed the presence of two truncated spliced variants, but no full-length mRNA. Total amount of bestrophin-3 mRNA increased after HI, but showed only minor injury-related change. However, the splice variants of bestrophin-3 mRNA were differentially regulated after HI depending on the presence of tissue injury. Our results show that bestrophin-3 is expressed in neonatal mouse brain after injury and in the human neonatal brain with pathology. In mouse brain bestrophin-3 protein is upregulated in a specific astrocyte population after injury and is co-expressed with nestin. Splice variants of bestrophin-3 mRNA respond differently to HI, which might indicate their different roles in tissue injury.

Serological reactivity to Anaplasma phagocytophilum in neoehrlichiosis patients.

The tick-borne bacterium Candidatus (Ca.) Neoehrlichia (N.) mikurensis is a cause of "fever of unknown origin" because this strict intracellular pathogen escapes detection by routine blood cultures. Case reports suggest that neoehrlichiosis patients may display serological reactivity to Anaplasma (A.) phagocytophilum. Since Anaplasma serology is part of the diagnostic work-up of undetermined fever in European tick-exposed patients, we wanted to investigate (1) the prevalence of A. phagocytophilum seropositivity among neoehrlichiosis patients, (2) the frequency of misdiagnosed neoehrlichiosis patients among A. phagocytophilum seropositive patients, and (3) the frequency of A. phagocytophilum and Ca. N. mikurensis co-infections. Neoehrlichiosis patients (n = 18) were analyzed for A. phagocytophilum IgM and IgG serum antibodies by indirect immunofluorescence assay. Serum samples from suspected anaplasmosis patients (n = 101) were analyzed for bacterial DNA contents by singleplex PCR specific for A. phagocytophilum and Ca. N. mikurensis, respectively. One fifth of the neoehrlichiosis patients (4/18) were seropositive for IgM and/or IgG to A. phagocytophilum at the time of diagnosis. Among the patients with suspected anaplasmosis, 2% (2/101) were positive for Ca. N. mikurensis by PCR whereas none (0/101) had detectable A. phagocytophilum DNA in the serum. To conclude, patients with suspected anaplasmosis may in fact have neoehrlichiosis. We found no evidence of A. phagocytophilum and Ca. N. mikurensis co-infections in humans with suspected anaplasmosis or confirmed neoehrlichiosis.

Aldosterone to Renin Ratio as a Screening Instrument for Primary Aldosteronism in a Middle-Aged Population with Atrial Fibrillation.

Atrial fibrillation seems to be overrepresented among patients with primary aldosteronism. The aim of this study was to determine the usefulness of aldosterone to renin ratio as a screening instrument for primary aldosteronism in an atrial fibrillation population with relatively low cardiovascular risk profile. A total of 149 patients <65 years and with history of AF were screened for primary aldosteronism using aldosterone to renin ratio. Pathologically increased aldosterone to renin ratio (>65 pmol/mIU) was found in 15 participants (10.1%). Further investigation of the positive screened participants and confirmatory saline infusion test resulted in a diagnosis of primary aldosteronism in four individuals out of 149 (2.6%). Three out of the four individuals with primary aldosteronism had previously been diagnosed with hypertension, but only one out of the four had uncontrolled blood pressure, that is, >140/90 mmHg. All participants had normal potassium levels. Individuals with increased aldosterone to renin ratio had significantly higher mean systolic and diastolic blood pressure in comparison to participants with normal aldosterone to renin ratio (136 vs. 126 mmHg, p=0.02 and 84 vs. 78 mmHg, p=0.02). These findings suggest that assessment of aldosterone to renin ratio can be useful for identification of underlying primary aldosteronism in patients with diagnosed atrial fibrillation and hypertension in spite of well controlled blood pressure and normokalemia.

Depression and subsequent risk of Parkinson disease: A nationwide cohort study.

OBJECTIVE: To investigate the long-term risk of Parkinson disease (PD) after depression and evaluate potential confounding by shared susceptibility to the 2 diagnoses. METHODS: The nationwide study cohort included 140,688 cases of depression, matched 1:3 using a nested case-control design to evaluate temporal aspects of study parameters (total, n = 562,631). Potential familial coaggregation of the 2 diagnoses was investigated in a subcohort of 540,811 sibling pairs. Associations were investigated using multivariable adjusted statistical models. RESULTS: During a median follow-up period of 6.8 (range, 0-26.0) years, 3,260 individuals in the cohort were diagnosed with PD. The multivariable adjusted odds ratio (OR) for PD was 3.2 (95% confidence interval [CI], 2.5-4.1) within the first year of depression, decreasing to 1.5 (95% CI, 1.1-2.0) after 15 to 25 years. Among participants with depression, recurrent hospitalization was an independent risk factor for PD (OR, 1.4; 95% CI, 1.1-1.9 for ≥5 vs 1 hospitalization). In family analyses, siblings' depression was not significantly associated with PD risk in index persons (OR, 1.1; 95% CI, 0.9-1.4). CONCLUSIONS: The time-dependent effect, dose-response pattern for recurrent depression, and lack of evidence for coaggregation among siblings all indicate a direct association between depression and subsequent PD. Given that the association was significant for a follow-up period of more than 2 decades, depression may be a very early prodromal symptom of PD, or a causal risk factor.

Low muscle strength in late adolescence and Parkinson disease later in life.

OBJECTIVE: To evaluate maximal isometric muscle force at 18 years of age in relation to Parkinson disease (PD) later in life. METHODS: The cohort consisted of 1,317,713 men who had their muscle strength measured during conscription (1969-1996). Associations between participants' muscle strength at conscription and PD diagnoses, also in their parents, were examined using multivariate statistical models. RESULTS: After adjustment for confounders, the lowest compared to the highest fifth of handgrip strength (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.06-1.79), elbow flexion strength (HR 1.34, 95% CI 1.02-1.76), but not knee extension strength (HR 1.24, 95% CI 0.94-1.62) was associated with an increased risk of PD during follow-up. Furthermore, men whose parents were diagnosed with PD had reduced handgrip (fathers: mean difference [MD] -5.7 N [95% CI -7.3 to -4.0]; mothers: MD -5.0 N [95% CI -7.0 to -2.9]) and elbow flexion (fathers: MD -4.3 N [95% CI -5.7 to -2.9]; mothers: MD -3.9 N [95% CI -5.7 to -2.2]) strength, but not knee extension strength (fathers: MD -1.1 N [95% CI -2.9 to 0.8]; mothers: MD -0.7 N [95% CI -3.1 to 1.6]), than those with no such familial history. CONCLUSIONS: Maximal upper extremity voluntary muscle force was reduced in late adolescence in men diagnosed with PD 30 years later. The findings suggest the presence of subclinical motor deficits 3 decades before the clinical onset of PD.

Cardiovascular response to stress and perceived stress is not altered 40 years after hypertensive pregnancies.

OBJECTIVE: Women experiencing hypertensive pregnancies have an increased risk for cardiovascular disease. Whether stress increase the risk is unknown. The objective was to test if cardiovascular response to stress and/or perceived stress differed in relation to blood pressure status during pregnancy 40 years earlier. METHODS: Cardiovascular response was examined with mental stress test, and perceived stress was evaluated with a questionnaire in 105 women. RESULTS: Resting heart rate was higher, and pulse reactivity was lower in women with previous hypertensive pregnancies. Neither blood pressure nor perceived stress differed. CONCLUSION: Response to physical or psychological stress is not affected many years after pregnancy.

Parkinson's disease: a population-based investigation of life satisfaction and employment.

OBJECTIVE: To investigate relationships between individuals' socioeconomic situations and quality of life in working-aged subjects with Parkinson's disease. METHODS: A population-based cohort comprising 1,432 people with Parkinson's disease and 1,135 matched controls, who responded to a questionnaire. Logistic regression analysis was performed to identify factors associated with life satisfaction and likelihood of employment. RESULTS: In multivariate analyses, Parkinson's disease was associated with an increased risk of dissatisfaction with life (odds ratio (OR) = 5.4, 95% confidence interval (95% CI) = 4.2-7.1) and reduced likelihood of employment (OR = 0.30, 95% CI = 0.25-0.37). Employers' support was associated with greater likelihood of employment (p < 0.001). Twenty-four percent of people with Parkinson's disease for ≥ 10 years remained employed and 6% worked full-time. People with Parkinson's disease also more frequently experienced work demands that exceeded their capacity; this factor and unemployment independently correlated with greater risk of dissatisfaction with life (both p < 0.05). CONCLUSION: People with Parkinson's disease have an increased risk of dissatisfaction with life. Employment situation is important for general life satisfaction among working-aged individuals. People with Parkinson's disease appear to find it difficult to meet the challenge of achieving a balanced employment situation.

One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial: "Continuum of care for frail older people".

BACKGROUND: The intervention; "Continuum of Care for Frail Older People", was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person's own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL). METHODS: The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR). RESULTS: A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 - 4.68) and (2.04, 95% CI; 1.03 - 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 - 0.98) compared to the control group. CONCLUSIONS: The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01260493.

Simulation team training for improved teamwork in an intensive care unit.

PURPOSE: This study aims to describe implementation of simulator-based medical team training and the effect of this programme on inter-professional working in an intensive care unit (ICU). DESIGN/METHODOLOGY/APPROACH: Over a period of two years, 90 percent (n = 152) of the staff of the general ICU at Karolinska University Hospital, Huddinge, Sweden, received inter-professional team training in a fully equipped patient room in their own workplace. A case study method was used to describe and explain the planning, formation, and results of the training programme. FINDINGS: In interviews, the participants reported that the training had increased their awareness of the importance of effective communication for patient safety. The intervention had even had an indirect impact by creating a need to talk, not only about how to communicate efficaciously, but also concerning difficult care situations in general. This, in turn, had led to regular reflection meetings for nurses held three times a week. Examples of better communication in acute situations were also reported. However, the findings indicate that the observed improvements will not last, unless organisational features such as staffing rotas and scheduling of rounds and meetings can be changed to enable use of the learned behaviours in everyday work. Other threats to sustainability include shortage of staff, overtime for staff, demands for hospital beds, budget cuts, and poor staff communication due to separate meetings for nurses and physicians. ORIGINALITY/VALUE: The present results broaden our understanding of how to create and sustain an organizational system that supports medical team training.

Cardiovascular and metabolic characteristics 40 years after hypertensive pregnancies: a long-term follow-up study of mothers.

OBJECTIVES: Maternal cardiovascular morbidity is increased after hypertensive pregnancies (HTP). The pathways from complicated pregnancies to future cardiovascular disease are complex. The aim of the present study was to test the hypothesis that different cardiovascular mechanisms are changed in women who experienced HTP four decades earlier in comparison to women with normotensive pregnancies. METHODS: One hundred and five women (50 with hypertensive and 55 with normal pregnancies) were examined with anthropometric measurements; office blood pressure, ambulatory blood pressure and central blood pressure, pulse wave velocity, augmentation index, intimal-media thickness, echocardiography and laboratory measurements. In addition another 204 women were followed-up by a questionnaire regarding their pregnancy 40 years ago, as well as their present health status and medications. RESULTS: Women with HTP had more often diagnosed hypertension when compared with women with normal pregnancies (50 vs. 31%, respectively; P = 0.046), but the groups did not differ in any blood pressure levels. HTP were associated with higher pulse wave velocity (8.8 m/s vs. 7.8 m/s, P = 0.021), and higher levels of P-glucose (5.7 mmol/l vs. 5.2 mmol/l, P = 0.022), P-HbA1c (4.4% vs. 4.2%, P = 0.010) and noradrenaline (2.45 mmol/l vs. 2.11 mmol/l, P = 0.040) when compared with normotensive pregnancies. Women followed up with a questionnaire reported deteriorated cardiovascular health compared to women attending the clinical investigations of the study. CONCLUSION: HTP are associated with impairment in vascular function and metabolic status 40 years postpartum despite well controlled blood pressure levels.

Reduced anti-contractile effect of perivascular adipose tissue on mesenteric small arteries from spontaneously hypertensive rats: role of Kv7 channels.

Perivascular adipose tissue (PVAT) has been shown to produce vasoactive substances and regulate vascular tone. This function of PVAT has been reported to be altered in hypertension. However, the underlying mechanisms are not fully understood. In this study we used age-matched normotensive Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) as well as Sprague-Dawley rats and tested effects of PVAT on mesenteric small arteries. Vessels were mounted in a Mulvany-Halpern myograph and cumulative concentration-response relations to noradrenaline were determined in the presence or absence of PVAT. We found that PVAT has an anti-contractile effect on mesenteric small vessels, irrespective of strains. A reduced effect of PVAT was observed in SHR compared to WKY rats; the difference between strains was eliminated by 10 µM XE991, a blocker of Kv7 (KCNQ) voltage-dependent potassium channels. The anti-contractile effect of PVAT was not affected by depolarizing smooth muscle cells with high K(+) solution. Sensitivities to exogenous vasodilators acetylcholine or sodium nitroprusside were not potentiated but reduced in vessels with PVAT. Our results suggest that the reduced anti-contractile effect of PVAT in SHR correlates with a deficiency in Kv7 channels. Diffusion hindrance of PVAT is also a factor that should be considered in investigations on rat mesenteric small arteries.

Implementing organisation and management innovations in Swedish healthcare: lessons from a comparison of 12 cases.

PURPOSE: The purpose of this paper is to compare the implementation of 12 different organisation and management innovations (OMIs) in Swedish healthcare, to discover the generic and specific factors important for successful healthcare improvement change in a public health system. DESIGN/METHODOLOGY/APPROACH: Longitudinal cross-case comparison of 12 case studies was employed, where each case study used a common framework for collecting data about the process of change, the content of the change, the context, and the intermediate and final outcomes. FINDINGS: Clinical leaders played a more important part in the development of these successful service innovations than managers. Strategies for and patterns of change implementation were found to differ according to the type of innovation. Internal organisational context factors played a significant role in the development of nearly all, but external factors did not. "Developmental evolution" better described the change process than "implementation". RESEARCH LIMITATIONS/IMPLICATIONS: The 12 cases were all of relatively successful change processes: some unsuccessful examples would have provided additional testing of the hypotheses about what would predict successful innovation which were used in the case comparison. The cross-case comparative hypothesis testing method allows systematic comparison if the case data are collected using similar frameworks, but this approach to management research requires considerable resources and coordination. PRACTICAL IMPLICATIONS: Management innovations that improve patient care can be carried out successfully by senior clinicians, under certain circumstances. A systematic approach is important both for developing and adapting an innovation to a changing situation. A significant amount of time was required for all involved, which could be reduced by "fast-tracking" approval for some types of change. ORIGINALITY/VALUE: This is the first empirical report comparing longitudinal and contextualised findings from a number of case studies of different organisational and management healthcare innovations. The findings made possible explanations for success factors and useful practical recommendations for conditions needed to nurture such innovation in public healthcare.

'Information on the fly': Challenges in professional communication in high technological nursing. A focus group study from a radiotherapy department in Sweden.

BACKGROUND: Radiotherapy (RT) units are high-tech nursing environments. In Sweden, RT registered nurses (RNs) provide and manage RT in close collaboration with other professional groups, as well as providing nursing care for patients with cancer. Communication demands on these RNs are thus particularly complex. In this study, we aimed to better understand problems, strengths and change needs related to professional communication with and within the RT department, as a basis for developing a situation-specific intervention. METHODS: Focus groups discussions (FGDs) were conducted with different professional (RNs, assistant nurses, physicians, engineers and physicists) and user stakeholders. Transcripts of the FGDs were inductively analyzed by a team of researchers, to generate clinically relevant and useful data. RESULTS: These findings give insight into RT safety climate and are presented under three major headings: Conceptualization of professional domains; Organization and leadership issues; and Communication forms, strategies and processes. The impact of existing hierarchies, including how they are conceptualized and acted out in practice, was noted throughout these data. Despite other differences, participating professionals agreed about communication problems related to RT, i.e. a lack of systems and processes for information transfer, unclear role differentiation, a sense of mutual disrespect, and ad hoc communication taking place 'on the fly'. While all professional groups recognized extensive communication problems, none acknowledged the potential negative effects on patient safety or care described in the FGD with patient representatives. While RNs often initially denied the existence of a hierarchy, they placed themselves on a hierarchy in their descriptions, describing their own role as passive, with a sense of powerlessness. Potential safety hazards described in the FGDs include not reporting medical errors and silently ignoring or actively opposing new guidelines and regulations. CONCLUSIONS: There is a risk that RNs who view themselves as disenfranchised within an organization will act with passive resistance to change, rather than as change promoters. As interventions to strengthen teams cannot be stronger than the weakest link, RNs may need support in the transition "from silence to voice" in order to take a position of full professional responsibility in a multi-professional health care team.

Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people.

BACKGROUND: Frail elderly people need an integrated and coordinated care. The two-armed study "Continuum of care for frail elderly people" is a multi-professional and multidimensional intervention for frail community-dwelling elderly people. It was designed to evaluate whether the intervention programme for frail elderly people can reduce the number of visits to hospital, increase satisfaction with health and social care and maintain functional abilities. The implementation process is explored and analysed along with the intervention. In this paper we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants. METHODS/DESIGN: The study is a randomised two-armed controlled trial with follow ups at 3, 6 and 12 months. The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community. Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living. Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician, severe cognitive impairment and palliative care. The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption. The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process. DISCUSSION: The design of the study, the randomisation procedure and the protocol meetings were intended to ensure the quality of the study. The implementation of the intervention programme is followed and analysed throughout the whole study, which enables us to generate knowledge on the process of implementing complex interventions. The intervention contributes to early recognition of both the elderly peoples' needs of information, care and rehabilitation and of informal caregivers' need of support and information. This study is expected to show positive effects on frail elderly peoples' health care consumption, functional abilities and satisfaction with health and social care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01260493.

Influence of chronic hormone replacement therapy on left ventricular mass and serum-ACE activity.

AIMS: The aim of this investigation was to study the effects of hormone replacement therapy (HRT) on left ventricular mass (LVM) and serum-angiotensin-converting enzyme (ACE) activity (S-ACE) in well controlled hypertensive postmenopausal women. METHODS: In this prospective, randomized, crossover, double-blind trial we studied 20 well controlled hypertensive postmenopausal women who received 6 months of HRT and 6 months of placebo on top of antihypertensive treatment. Two-dimensional M-mode, office blood pressure, 24-h ambulatory blood pressure (ABPM), S-estradiol and S-ACE activity were investigated at baseline, after 6 and 12 months. RESULTS: LVM was significantly influenced by HRT (analysis of variance, ANOVA, p<0.01). However, the order in randomization of HRT and placebo had an impact on the analysis of LVM reduction (baseline - HRT - placebo: ns; baseline - placebo - HRT: p<0.01 ANOVA). Only the women lacking blockade of the renin-angiotensin-aldosterone system (RAAS) as antihypertensive treatment (n=10) experienced a reduction in LVM and a tendency of decreased S-ACE activity in response to HRT compared with baseline (p< 0.05 and p= 0.06 respectively). CONCLUSIONS: Six months of HRT resulted in significant reduction of LVM without any change in ABPM. HRT may reduce LVM through interaction with the RAAS, since hypertensive women without RAAS blockade exhibited an effect of HRT on LVM and S-ACE activity, which was not seen in women on RAAS blockade.