Risk factors for seroma formation after axillary lymph node dissection with special focus on the impact of early shoulder exercise.

BACKGROUND: Shoulder and arm dysfunction such as reduced range of motion (ROM) and seroma formation, are common complications following axillary lymph node dissection (ALND). There are conflicting results on the effect of early postoperative exercise on the risk of seroma. This study aims to present incidence of symptomatic seroma formation in a large, population-based cohort, and assesses whether early shoulder mobilization, and other common patient and treatment-related factors are predictors of seroma. METHODS: This observational cohort study at the Surgical clinic at Lund University Hospital in Sweden, included 217 consecutive patients who underwent ALND due to breast cancer, cutaneous malignant melanoma (CMM), or carcinoma of unknown primary. A shoulder exercise program was introduced on the first postoperative day and data were collected at routine follow-up 4-6 weeks postsurgery. Main outcome was the strength of the associations between postsurgery exercise and seroma incidence based on logistic regression analyses, supported by data on seroma volume and number of aspirations. RESULTS: Two hundred patients completed the study. The overall seroma incidence was 67.5% and the odds of seroma were lower for patients practicing ROM exercise two times/day versus 0-1 time/day (OR 0.42, 95% CI 0.18-0.96, p = .038). ROM exercise greater than two times/day did not increase the volume, neither did the arm cycling exercise. ALND combined with mastectomy and CMM surgery were associated with larger seroma volumes (1116 ± 1068ml, p = .006) and (1318 ± 920 ml, p < .001), respectively, compared to the breast conserving surgery (537 ± 478ml) while neoadjuvant chemotherapy showed no influence. The effect of age, patients ≥60 years compared to younger, or BMI ≥ 30.0 were weaker (p = .08). CONCLUSIONS: Extensive surgical treatments for breast cancer and malignant melanoma produces more seroma, and higher age and obesity may also influence the risk. ROM exercises twice daily predict a lower incidence of seroma following ALND, and more frequent shoulder exercise do not increase the volumes.

Impact on Health-Related quality of life after wearing compression garment or not for six months in women with mild breast cancer-related arm lymphedema. A cross-sectional study.

BACKGROUND: Women with mild breast cancer-related arm lymphedema (BCRAL) mostly receive treatment with compression garments and instructions in self-care to prevent the progression of lymphedema. However, wearing a compression garment may be experienced as negative and may affect health-related quality of life (HRQOL) more than the lymphedema itself. The aim of this study was to investigate if there is a difference in lymphedema-specific HRQOL, between women with mild BCRAL wearing compression garments or not for 6 months. MATERIAL AND METHODS: Participants with mild BCRAL (Lymphedema relative volume <10%) rated their HRQOL by the Lymphedema Quality of Life Inventory (LyQLI), 6 months after diagnosis and being randomized to compression group (CG) or non-compression group (NCG). Both groups received self-care instructions, and the CG was treated with a standard compression garment, compression class 1. Data from 51 women (30 in the CG and 21 in the NCG), were analyzed. RESULTS: Both the CG and the NCG experienced a low negative impact on HRQOL in physical, psychosocial, and practical domains (score <1). However, the CG experienced a higher negative impact on median HRQOL in the practical domain compared to the NCG, 0.23/0.08 respectively, (p = 0.026). In the specific items, more participants in the CG reported a negative impact on HRQOL compared to the NCG in employment activities 23%/0%, (p = 0.032), embarrassment by lymphedema/compression garments 33%/5%, (p = 0.017), feeling discomfort/embarrassment while doing sports and hobbies 30%/5%, (p = 0.034) and having to answer questions about the lymphedema 27%/0% (p = 0.015). CONCLUSION: Overall, the lymphedema-specific HRQOL was high after 6 months in women with mild lymphedema, with only a minor difference between the groups. Some women may however perceive practical and emotional issues with the compression garment. These aspects should be considered in patient education and when planning/evaluating treatment. Trial registration: ISRCTN51918431.

Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphedema: a randomized controlled trial.

BACKGROUND: Early diagnosis and compression treatment are important to prevent progression in breast cancer-related arm lymphedema (BCRAL). However, some mild BCRAL can be reversible, and therefore, compression treatment may not be needed. The aim of this study was to investigate the proportion of women with mild BCRAL showing progression/no progression of lymphedema after treatment with or without compression garments, differences in changes of lymphedema relative volume (LRV), local tissue water and subjective symptoms during 6 months. Also, adherence to self-care was examined. MATERIAL AND METHODS: Seventy-five women diagnosed with mild BCRAL were randomized to a compression group (CG) or noncompression group (NCG). Both groups received self-care instructions, and the CG were treated with a standard compression garment (ccl 1). Women in the NCG who progressed in LRV ≥2%, or exceeded 10% dropped out, and received appropriate treatment. The proportion showing progression/no progression of LRV, and changes in LRV was measured by Water Displacement Method. Changes in local tissue water were measured by Tissue Dielectric Constant (TDC), subjective symptoms by Visual Analogue Scale, and self-care by a questionnaire. RESULTS: A smaller proportion of LRV progression was found in the CG compared to the NCG at 1, 2 and 6 months follow-up (p ≤ 0.013). At 6 months, 16% had progression of LRV in the CG, compared to 57% in the NCG, (p = 0.001). Thus, 43% in the NCG showed no progression and could manage without compression. Also, CG had a larger reduction in LRV, at all time-points (p ≤ 0.005), and in the highest TDC ratio, when same site followed, at 6 months (p = 0.025). Subjective symptoms did not differ between the groups, except at 1 month, where the CG experienced more reduced tension (p = 0.008). There were no differences in adherence to self-care. CONCLUSION: Early treatment with compression garment can prevent progression in mild BCRAL. Trial registration: ISRCT nr ISRCTN51918431.

Depression was associated with younger age, female sex, obesity, smoking, and physical inactivity, in 1027 patients with newly diagnosed type 2 diabetes: a Swedish multicentre cross-sectional study.

BACKGROUND: Depression is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). The aims were to explore the prevalence of depression, anxiety, antidepressant use, obesity, Hemoglobin A1c > 64 mmol/mol, life-style factors, pre-existing CVD, in patients with newly diagnosed T2D; to explore associations with depression; and to compare with Swedish general population data. METHODS: Multicentre, cross-sectional study. INCLUSION CRITERIA: adults with serologically verified newly diagnosed T2D. Included variables: age, sex, current depression and anxiety (Hospital Anxiety and Depression Scale), previous depression, antidepressant use, obesity (BMI ≥ 30 and ≥ 40 kg/m2), Hemoglobin A1c, pre-existing CVD. Logistic regression analyses were performed. RESULTS: In 1027 T2D patients, aged 18-94 years, depression was associated with age (per year) (inversely) (odds ratio (OR) 0.97), anxiety (OR 12.2), previous depression (OR 7.1), antidepressant use (OR 4.2), BMI ≥ 30 kg/m2 (OR 1.7), BMI ≥ 40 kg/m2 (OR 2.3), smoking (OR 1.9), physical inactivity (OR 1.8), and women (OR 1.6) (all p ≤ 0.013). Younger women (n = 113), ≤ 59 years, compared to younger men (n = 217) had higher prevalence of current depression (31% vs 12%), previous depression (43 vs 19%), anxiety (42% vs 25%), antidepressant use (37% vs 12%), BMI ≥ 30 kg/m2 (73% vs 60%) and BMI ≥ 40 kg/m2) (18% vs 9%), and smoking (26% vs 16%) (all p ≤ 0.029). Older women (n = 297), ≥ 60 years, compared to older men (n = 400) had higher prevalence of previous depression (45% vs 12%), anxiety (18% vs 10%), antidepressant use (20% vs 8%), BMI ≥ 30 kg/m2 (55% vs 47%), BMI ≥ 40 kg/m2 (7% vs 3%) (all p ≤ 0.048), but not of current depression (both 9%). Compared to the Swedish general population (depression (women 11.2%, men 12.3%) and antidepressant use (women 9.8%, men 5.3%)), the younger women had higher prevalence of current depression, and all patients had higher prevalence of antidepressant use. CONCLUSIONS: In patients with newly diagnosed T2D, the younger women had the highest prevalence of depression, anxiety, and obesity. The prevalence of depression in young women and antidepressant use in all patients were higher than in the Swedish general population. Three risk factors for CVD, obesity, smoking, and physical inactivity, were associated with depression.

Genetic controls of short- and long-term stomatal CO2 responses in Arabidopsis thaliana.

BACKGROUND AND AIMS: The stomatal conductance (gs) of most plant species decreases in response to elevated atmospheric CO2 concentration. This response could have a significant impact on plant water use in a future climate. However, the regulation of the CO2-induced stomatal closure response is not fully understood. Moreover, the potential genetic links between short-term (within minutes to hours) and long-term (within weeks to months) responses of gs to increased atmospheric CO2 have not been explored. METHODS: We used Arabidopsis thaliana recombinant inbred lines originating from accessions Col-0 (strong CO2 response) and C24 (weak CO2 response) to study short- and long-term controls of gs. Quantitative trait locus (QTL) mapping was used to identify loci controlling short- and long-term gs responses to elevated CO2, as well as other stomata-related traits. KEY RESULTS: Short- and long-term stomatal responses to elevated CO2 were significantly correlated. Both short- and long-term responses were associated with a QTL at the end of chromosome 2. The location of this QTL was confirmed using near-isogenic lines and it was fine-mapped to a 410-kb region. The QTL did not correspond to any known gene involved in stomatal closure and had no effect on the responsiveness to abscisic acid. Additionally, we identified numerous other loci associated with stomatal regulation. CONCLUSIONS: We identified and confirmed the effect of a strong QTL corresponding to a yet unknown regulator of stomatal closure in response to elevated CO2 concentration. The correlation between short- and long-term stomatal CO2 responses and the genetic link between these traits highlight the importance of understanding guard cell CO2 signalling to predict and manipulate plant water use in a world with increasing atmospheric CO2 concentration. This study demonstrates the power of using natural variation to unravel the genetic regulation of complex traits.

Bone marrow- and adipose tissue-derived mesenchymal stem cells from donors with coronary artery disease; growth, yield, gene expression and the effect of oxygen concentration.

Mesenchymal stem cells (MSCs) for cardiovascular cell therapy are procured from different sources including bone marrow and adipose tissue. Differently located MSCs differ in growth potential, differentiation ability and gene expression when cultured in vitro, and studies show different healing abilities for different MSC subgroups. In this study, bone marrow derived MSCs (BMSCs) and adipose tissue derived MSCs (ADSCs) from six human donors with coronary artery disease were compared for growth potential and expression of target genes (Angpt1, LIF, HGF, TGF-ß1 and VEGF-A) in response to exposure to 1% and 5% O2, for up to 48 h. We found greater growth of ADSCs compared to BMSCs. ADSCs expressed higher levels of Angpt1, LIF and TGF-ß1 and equal levels of VEGF-A and HGF as BMSCs. In BMSCs, exposure to low oxygen resulted in upregulation of TGF-ß1, whereas other target genes were unaffected. Upregulation was only present at 1% O2. In ADSCs, LIF was upregulated in both oxygen concentrations, whereas Angpt1 was upregulated only at 1% O2. Different response to reduced oxygen culture conditions is of relevance when expanding cells in vitro prior to administration. These findings indicate ADSCs as better suited for cardiovascular cell therapy compared to BMSCs.

In search for the "humane": staffs' perspectives on everyday activities in a nursing home.

Objectives: To better understand how a dialogue about the influence of nursing home residents on their everyday activities evolve among diverse practitioners and to identify the consequences of such an understanding in practice.Methods: Inspired by a collaborative approach, five workshops, one focus group and follow up interviews were conducted. The participants were 19 diverse practitioners. Analysis followed a dialogical approach.Findings: Tensions, opportunities and challenges were articulated and discussed during the workshops and are developed in: a) Bypassing the "humane"? The dilemma between using shields preventing engagement or acting in a clandestine manner b)"What is our stance?" Seeking common ground on which to stand regarding everyday activities and c) Recognising expertise and seeking connections.Discussion: For the staff, acting in a clandestine manner seems to create ways of enabling "humane" practices towards nursing home residents. The "clandestine manners" seem to be grounded in an effort on the part of the staff to make sense of the everyday activities for the nursing home residents. These "clandestine manners" could be seen as responses to institutional routines and a lack of common ground on the understanding of everyday activities in the context of nursing homes.

Cross-border spread of blaNDM-1- and blaOXA-48-positive Klebsiella pneumoniae: a European collaborative analysis of whole genome sequencing and epidemiological data, 2014 to 2019.

Analysis of sequencing data for 143 blaNDM-1- and blaOXA-48-positive Klebsiella pneumoniae isolates from 13 European national collections and the public domain resulted in the identification of 15 previously undetected multi-country transmission clusters. For 10 clusters, cases had prior travel/hospitalisation history in countries outside of the European Union including Egypt, Iran, Morocco, Russia, Serbia, Tunisia and Turkey. These findings highlight the benefit of European whole genome sequencing-based surveillance and data sharing for control of antimicrobial resistance.

Professional pride: A qualitative descriptive study of nursing home staff's experiences of how a quality development project influenced their work.

AIMS AND OBJECTIVES: To explore and describe how daily work at a nursing home had been influenced by a quality improvement project, from the perspective of direct care staff. BACKGROUND: Deficiencies in nursing home care are widely reported, often with a focus on lack of competence among direct care staff. The present trend in quality development in nursing homes brings direct care staff's perspectives into focus through participatory action research approaches. Still, little is known about how staff experience the impact of such projects on their everyday work. DESIGN: The study was designed as an interpretive descriptive study, based on interviews with nursing home staff. The methods were conducted in accordance with the SRQR guidelines. RESULTS: The analysis revealed that the participants reasoned on whether the improvement project contributed to their possibilities perform their work at the unit for the benefit of the residents. This was strongly connected to their professional pride. The participants reflected on this through three changes generated by the project: (a) participating in project activities-supporting or threatening daily work at the unit, (b) from performing individual duties towards a shared responsibility and (c) confirming and strengthening competence that brings the everyday situation of residents into focus. CONCLUSION: The importance of professional pride identified in this study points towards a need for reducing barriers for direct care staff to express and develop competences they regard as part of their professional identity. The findings also shed some light on competence that brings the everyday situation of residents into focus as a driving force behind lack of compliance and resistance to change. RELEVANCE TO CLINICAL PRACTICE: The findings indicate a call for quality development designs to reduce barriers for care staff to express and develop knowledge that they regard as part of their professional identity.

Health-related quality of life in patients with lymphoedema - a cross-sectional study.

INTRODUCTION: Lymphoedema may cause complex problems that can strongly influence patients' health-related quality of life (HRQoL). The main purpose of this study was to investigate the impact of lymphoedema on HRQoL in patients with varying forms of lymphoedema. METHODS: The Lymphoedema Quality of Life Inventory (LyQLI), measuring three domains, physical, psychosocial and practical, and the Short Form 36 Health Survey Questionnaire (SF-36), measuring eight health domains, were sent to 200 lymphoedema patients. Out of those who answered both questionnaires, 88 patients had lymphoedema secondary to cancer treatment and they additionally received the Functional Assessment of Cancer Therapy Scale-General (FACT-G). The relation between continuous variables and the three domains were analysed by Spearman's correlation coefficients, and Kruskal-Wallis test was used to analyse categorical variables. RESULTS: Altogether 129 patients completed the LyQLI and SF-36 and 79 of them also completed FACT-G. Twenty per cent had a high mean score (≥2.0) in at least one domain of the LyQLI, thus having a low HRQoL. Lower HRQoL was found in the practical domain of LyQLI in patients with lower limb lymphoedema compared to patient with lymphoedema in upper limb or head/neck (p = 0.002) and in patients working part-time compared to patients working full-time (p = 0.005). The impact on HRQoL tended to decrease with age, with a significant correlation in the psychosocial domain (rs = 0.194, p = 0.028). Compared with the general Swedish population, patients with lymphoedema scored significantly lower in general health (p = 0.006), vitality (p = 0.002) and social functioning (p = 0.025) assessed by the SF-36. From a cancer-specific view, HRQoL was similar to other Swedish studies using the FACT-G. CONCLUSIONS: This study indicates that about 20% of the patients with lymphoedema had major impact on their HRQoL. More effort and research is needed to identify, understand and support groups of patients with severe lymphoedema-related problems.

Supporting patients learning to live with diabetes: a phenomenological study.

This article describes a study of the phenomenon of supporting patients who are learning to live with diabetes, from a diabetes specialist nurse (DSN) perspective. Guided by principles of reflective lifeworld research, data from six interviews (four in groups and two individual) with 16 DSNs were analysed. The results show that, in order to support learning, DSNs use a self-critical approach with the insight that they should not take over responsibility for their patients' diabetes. The DSNs support, encourage and challenge the patients to self-reflect and take responsibility based on patients' own goals and needs. To provide support, DSNs need to assume a tactful, critically challenging approach, dare to confront patients' fears and other emotions and have the insight to know that the responsibility for learning and integration of the condition lies with the patient. To be able to support patients in this way, it is necessary that the DSN is mentored and supported in this role.

Multi-laboratory validation study of multilocus variable-number tandem repeat analysis (MLVA) for Salmonella enterica serovar Enteritidis, 2015.

Multilocus variable-number tandem repeat analysis (MLVA) is a rapid and reproducible typing method that is an important tool for investigation, as well as detection, of national and multinational outbreaks of a range of food-borne pathogens. Salmonella enterica serovar Enteritidis is the most common Salmonella serovar associated with human salmonellosis in the European Union/European Economic Area and North America. Fourteen laboratories from 13 countries in Europe and North America participated in a validation study for MLVA of S. Enteritidis targeting five loci. Following normalisation of fragment sizes using a set of reference strains, a blinded set of 24 strains with known allele sizes was analysed by each participant. The S. Enteritidis 5-loci MLVA protocol was shown to produce internationally comparable results as more than 90% of the participants reported less than 5% discrepant MLVA profiles. All 14 participating laboratories performed well, even those where experience with this typing method was limited. The raw fragment length data were consistent throughout, and the inter-laboratory validation helped to standardise the conversion of raw data to repeat numbers with at least two countries updating their internal procedures. However, differences in assigned MLVA profiles remain between well-established protocols and should be taken into account when exchanging data.

Lymphedema Quality of Life Inventory (LyQLI)-Development and investigation of validity and reliability.

PURPOSE: The purpose of this study was to reduce the 188-item Swedish Lymphedema Quality of Life Inventory (SLQOLI) to an abbreviated, clinically useful version (phase 1) and to test it for reliability and validity (phase 2). METHODS: In phase 1 correlation analysis, factor analysis, content validity assessment and expert panels were used to reduce the number of items in SLQOLI to 45 items, which was named, Lymphedema Quality of Life Inventory (LyQLI). In phase 2, LyQLI was sent to 200 patients with lymphedema. 126 patients completed the questionnaire twice to determine stability of the instrument over time. SF-36 was sent to the patients once, correlations between the three domains in LyQLI and the two sum scores Physical Health (PCS) and Mental Health (MCS) in SF-36 were used to assess concurrent validity. RESULTS: The 188-item SLQOLI was reduced to 45-item LyQLI. Four domains were reduced to three: physical, psychosocial and practical. Reliability estimates using ICC for the physical and psychosocial domains were 0.88 (p < 0.01) and 0.87 (p < 0.01), for the practical domain 0.87 (p < 0.01). Cronbach's alpha coefficients for the three domains were 0.88, 0.92 and 0.88, respectively. The physical domain correlated highly significantly with PCS, psychosocial highly significantly with MCS and practical equally highly significantly to both PCS and MCS. Using skewness coefficients, small floor effects in the items were found. CONCLUSION: The shorter LyQLI demonstrated good reliability and validity with potential use to assess quality of life in clinic settings and in further cross-sectional studies of patients with lymphedema.

Manual lymphatic drainage for lymphedema following breast cancer treatment.

BACKGROUND: More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling. OBJECTIVES: To assess the efficacy and safety of MLD in treating BCRL. SEARCH METHODS: We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24 May 2013. No language restrictions were applied. SELECTION CRITERIA: We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care. DATA COLLECTION AND ANALYSIS: We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD. MAIN RESULTS: Six trials were included. Based on similar designs, trials clustered in three categories.(1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction.(2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction for MLD (MD 7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.(3) MLD + compression therapy versus nonMLD treatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoring MLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P=0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus self-administered simple lymphatic drainage (SLD), and was significant for MLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe in all trials.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group.Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results.Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care.Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. AUTHORS' CONCLUSIONS: MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data.In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation.Findings were contradictory for function (range of motion), and inconclusive for quality of life.For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received.One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve.

Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective.

Lymphoedema after breast cancer surgery is a chronic condition. Lymphoedema treatment consists of information/advice, compression, physical exercise, skin care, and manual lymph drainage. Little is known about how patients experience, adapt, and respond to lymphoedema treatment. Thus, the purpose of the study was to investigate and describe women's perceptions of lymphoedema treatment after breast cancer surgery. Sixteen women with breast-cancer-related lymphoedema, recruited from four hospitals and two rehabilitation clinics, participated in the study. Semi-structured interviews were conducted and analysed using a phenomenographic method. Five qualitatively different categories of description could be identified: uncertainty, disappointment, guilt and shame, safety, and autonomy. The categories could be described based on a two-dimensional structure: the patients role (internal vs. external locus of control) and an understanding of lymphoedema as a chronic disease or a burden. The study has provided a deeper understanding of different ways in which patients perceive and respond to lymphoedema treatment. The present findings enable the lymphoedema therapist to individualise treatment and counselling based on each patient's approach to the patient role, ability to take responsibility for treatment, and acceptance of lymphoedema as a chronic disease.

U.S. and Swedish Student Learning Through Online Synchronous International Interactions.

There is a continued need to communicate global perspectives in occupational therapy education, but the literature addressing how to incorporate firsthand global experiences into campus learning environments is scant. This article describes how course-based synchronous interactions between U.S. undergraduate occupational science students and Swedish undergraduate occupational therapy students occur via online technology. In a 2014 pilot study, we thematically analyzed students' open-ended survey responses to discern what students learned through the interactive sessions. We also performed a content analysis of four audio-recorded interactive sessions to understand the content and nature of students' learning. Our findings suggest that course-based online synchronous interactions provide a positive way for students to learn about other cultures and global differences in occupational therapy practice. The findings also highlight needs for improvement relative to the structure and aims of the interactive sessions. We relate these findings to the global availability of technology and occupational therapists' cultural competence.

Weaning from mechanical ventilation: factors that influence intensive care nurses' decision-making.

AIM: The aim of the study was to describe the factors that influence intensive care nurses' decision-making when weaning patients from mechanical ventilation. BACKGROUND: Patients with failing vital function may require respiratory support. Weaning from mechanical ventilation is a process in which the intensive care nurse participates in both planning and implementation. DESIGN AND METHOD: A qualitative approach was used. The data were collected by means of semi-structured interviews with 22 intensive care nurses. The interviews were transcribed and analysed using qualitative content analysis. FINDINGS: One theme emerged: 'A complex nursing situation where the patient receives attention and which is influenced by the current care culture'. There was consensus that the overall assessment of the patient made by the intensive care nurse was the main factor that influenced the decision-making process. This assessment was a continuous process consisting of three factors: the patient's perspective as well as her/his physical and mental state. On the other hand, there was a lack of consensus about what other factors influenced the decision-making process. These factors included the care culture constituted by the characteristics of the team, the intensive care nurses' professional skills, personalities and ability to be present. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: The individual overall assessment of the patient enabled nursing care from a holistic perspective. Furthermore, the weaning process can be more effective and potential suffering reduced by creating awareness of the care culture's impact on the decision-making process.

The impact of climate on the geographical distribution of phytoplankton species in boreal lakes.

Here, we use a novel space-by-time approach to study large-scale changes in phytoplankton species distribution in Swedish boreal lakes in response to climate variability. Using phytoplankton samples from 27 lakes, evenly distributed across Sweden, all relatively unimpacted by anthropogenic disturbance and sampled annually between 1996 and 2010, we found significant shifts in the geographical distribution of 18 species. We also found significant changes in the prevalence of 45 species (33 became more common and 12 less common) over the study period. Using species distribution models and phytoplankton samples from 60 lakes sampled at least twice between 1992 and 2010, we evaluated the importance of climate variability and other environmental variables on species distribution. We found that temperature (e.g., extreme events and the duration of the growing season) was the most important predictor for species detections. Many cyanobacteria, chlorophytes, and, to a lesser extent, diatoms and zygnematophytes, showed congruent and positive responses to temperature. In contrast, precipitation explained little variation and was important only for a few taxa (e.g., Staurodesmus spp., Trachelomonas volvocina). At the community level, our results suggest a change in community composition at temperatures over 20 °C and growing seasons longer than 40 days. We conclude that climate is an important driver of the distributional patterns of individual phytoplankton species and may drive changes in community composition in minimally disturbed boreal lakes.

Have they done what they should? Moral reasoning in the context of translating older persons' everyday problems into eligible needs for home modification services.

This study explores how moral reasoning is expressed in matching health care with the problems older persons experience in their everyday life. Narrative data were collected from older persons who had applied for home modification services and from professionals involved in these services in Sweden. A theoretical framework, based on theories on the anthropology of morals, was applied to explore how the participants made conclusions about "what should be done." Moral reasoning was found to be guided by ideologies related to the historical and cultural context of the Swedish welfare state. Different interpretations of how these values should be expressed in specific situations led to different conclusions about what should be done. The study highlights the importance of understanding how values are enacted rather than what values different social agents have in order to understand how health care services can be designed and provided to support older persons' everyday life.