Characteristics and definitive outcomes of COVID-19 patients admitted to a secondary hospital intensive care unit in Sweden.

BACKGROUND AND AIMS: Most published reports of COVID-19 Intensive Care Unit (ICU) patients are from large tertiary hospitals and often present short-term or incomplete outcome data. There are reports indicating that ICUs with fewer beds are associated with higher mortality. This study aimed to investigate the definitive outcome and patient characteristics of the complete first wave of COVID-19 patients admitted to ICU in a secondary hospital. METHODS: In this prospective observational study, all patients with respiratory failure and a positive SARS-CoV-2 test admitted to Västerås Hospital ICU between 24 March and July 22, 2020 were included. The primary outcome was defined as 90-day mortality. Secondary outcomes included ICU length of stay, hospital length of stay, number of days with invasive ventilation, need for vasopressors/inotropes, and use of renal replacement therapy. RESULTS: Fifty-three patients were included. Median age (range) was 59 (33-76) and 74% were men. Obesity and hypertension were the most common comorbidities and 45% of the patients were born outside Europe. Ninety-day mortality was 30%. Median ICU length of stay (interquartile range) was 14 (5-24) days and the duration of invasive mechanical ventilation 16 (12-26) days. No patients received dialysis at 90-day follow-up. CONCLUSION: In this cohort of COVID-19 patients treated in a secondary hospital ICU, mortality rates were low compared to early studies from China, Italy, and the United States, but similar to other government-funded hospitals in Scandinavia. A preparatory reorganization enabled an increase in ICU capacity, hence avoiding an overwhelmed intensive care organization.

Gene expression profiling of archival tongue squamous cell carcinomas provides sub-classification based on DNA repair genes.

A subgroup of patients with squamous cell carcinoma of the head and neck (SCCHN) comprise young persons under the age of 40, who have not been heavily exposed to the classical risk factors, smoking and alcohol. The number of SCCHN in young adults, particularly tongue tumours, is increasing in several parts of the world. Here we employed a novel gene expression array methodology specifically developed for analysis of degraded RNA and investigated the expression of 502 cancer-related genes in archival paraffin-embedded SCCHN of the tongue from young (< or =40) and elderly patients (> or =50). Genes detected as de-regulated in tumours compared to non-malignant controls were in concordance with results from earlier studies of fresh frozen material. No genes were detected as significantly differentially expressed between young and old patients suggesting that the overall pathobiology of SCCHN is similar in young and old. Unsupervised clustering divided tumours into three groups, irrespective of age, where several differentially expressed DNA repair genes were a prominent separation factor. High levels of DNA repair genes associated with impaired therapeutic response to radiation, suggesting that DNA repair genes play a role in clinical outcome after radiotherapy.

Nurse strategies for optimising patient participation in nursing care.

UNLABELLED: THE STUDY'S RATIONALE: Patient participation is an essential factor in nursing care and medical treatment and a legal right in many countries. Despite this, patients have experienced insufficient participation, inattention and neglect regarding their problems and may respond with dependence, passivity or taciturnity. Accordingly, nurses strategies for optimising patient participation in nursing care is an important question for the nursing profession. AIM AND OBJECTIVE: The aim was to explore Registered Nurses' strategies to stimulate and optimise patient participation in nursing care. The objective was to identify ward nurses' supporting practices. METHODOLOGICAL DESIGN AND JUSTIFICATION: A qualitative research approach was applied. Three focus groups with experienced Registered Nurses providing inpatient somatic care (n = 16) were carried out. These nurses were recruited from three hospitals in West Sweden. The data were analysed using content analysis technique. ETHICAL ISSUES AND APPROVAL: The ethics of scientific work was adhered to. According to national Swedish legislation, no formal permit from an ethics committee was required. The participants gave informed consent after verbal and written information. RESULTS: Nurse strategies for optimising patient participation in nursing care were identified as three categories: 'Building close co-operation', 'Getting to know the person' and 'Reinforcing self-care capacity' and their 10 subcategories. CONCLUSIONS: The strategies point to a process of emancipation of the patient's potential by finding his/her own inherent knowledge, values, motivation and goals and linking these to actions. Nurses need to strive for guiding the patient towards attaining meaningful experiences, discoveries, learning and development. The strategies are important and useful to balance the asymmetry in the nurse-patient relationship in daily nursing practice and also in quality assurance to evaluate and improve patient participation and in education. However, further verification of the findings is recommended by means of replication or other studies in different clinical settings.

Prediction of postoperative pain after radical prostatectomy.

BACKGROUND: There is a belief that the amount of pain perceived is merely directly proportional to the extent of injury. The intensity of postoperative pain is however influenced by multiple factors aside from the extent of trauma. The purpose of the study was to evaluate the relationship between preoperative factors that have been shown to predict postoperative pain and the self-reports of pain intensity in a population of 155 men undergoing radical prostatectomy (RP), and also to investigate if previous pain score could predict the subsequent pain score. METHODS: The correlation between potential pain predictors and the postoperative pain experiences during three postoperative days was tested (Pitmans' test). By use of a logistic regression analysis the probability that a Visual Analogue Scale (VAS) score at one occasion would exceed 30 mm or 70 mm was studied, depending on previous VAS score, age, depression and pain treatment method. RESULTS: Age was found to be a predictor of VAS > 30 mm, with younger patients at higher risk for pain, and preoperative depression predicted VAS > 70 mm. The probability that VAS would exceed 30 mm and 70 mm was predicted only by previous VAS value. Day two however, patients with epidural analgesia were at higher risk for experiencing pain than patients with intrathecal or systemic opioid analgesia. CONCLUSION: The results show that it would be meaningful to identify RP patients at high risk for severe postoperative pain; i.e. younger and/or depressive patients who might benefit from a more aggressive therapy instituted in the very early postoperative period.

Postoperative pain management - the influence of surgical ward nurses.

AIM: To compare pain levels reported by patients with those documented by ward nurses and to find out to what extent the amount of opioids given correlated with the pain level. Secondly, to study if pain management and nurses' approaches to this task had improved during a two-year period, including an educational pain treatment program for ward staff. BACKGROUND: The management of postoperative pain continues to remain problematic and unsatisfactory and ward nurses play an important role for this task. DESIGN: The study was a cross-sectional, descriptive, two-part study based on survey data from both patients and nurses on two urology surgical wards. METHODS: Part I of the study included 77 patients and 19 nurses. Part II took place approximately two years later and included 141 patients and 22 nurses. Data were collected the day after surgery by asking patients about 'worst pain' experienced. The pain scores given by the patients were compared with those documented in the patients' records and with the doses of opioids administered. Nurses' approaches to pain management were sought after, by using a categorical questionnaire. RESULTS: The nurses' ability to assess pain in accordance with the patients' reports had increased slightly after two years even if and the number of documented pain scores had decreased. Forty per cent of the nurses reported that they did not use visual analogue scale and that they did not assess pain at both rest and activity, neither did one fourth evaluate the effect of given analgesics. CONCLUSION: The study showed a discrepancy in pain scoring between nurses and patients, where active treatment was related to nurses' documentation rather than to patients' scoring. RELEVANCE TO CLINICAL PRACTICE: The study shows a need for more accurate pain assessment, since the patient experiences and suffers pain and the nurse determines upon treatment.

Worst experiences of pain and conceptions of worst pain imaginable among nursing students.

AIM: This paper is a report of a study to explore nursing students' own worst experiences of pain as well as their conceptions of the worst pain imaginable. BACKGROUND: Pain is a personal experience, often assessed using a visual analogue scale. The endpoints of this scale are labelled with the extremes for pain experience (e.g. no pain to worst pain imaginable). People may understand the meaning of 'no pain', but it is unclear what meaning they assign to 'worst pain imaginable'. This indicates that a rating along the Visual Analogue Scale-line is dependent on the individual's previous experiences. METHODS: Data were collected during the autumn of 2002. In total, 549 nursing students completed a questionnaire focusing on two main questions: 'What is the worst experience of hurt, ache or pain you have had?' and 'What is the worst pain imaginable for you?' Content analysis was used for data analysis. RESULTS: The students' worst experience of pain was mostly related to acute or traumatic painful conditions, pain associated with female physiology, inflicted pain, psychological suffering and chronic painful conditions. The worst pain imaginable was described as condition-related pain, overwhelming pain, experiences of losses, deliberately inflicted pain, psychological suffering and as vicarious pain. CONCLUSION: The findings imply that nursing students, when they are imagining pain, include dimensions such as hope of relief, grief, control over the situation, powerlessness and empathy for and suffer with other people's pain. Further research is needed to explore why professional experience as a nurse diminishes the ability to imagine patients' pain.

An analysis of the concept of patient participation.

The concept of patient participation has an array of interpretations and lacks clarity. The purpose of this article is to explore the concept of patient participation within the context of nursing practice. The method described by Walker and Avant (1995) is used. The critical attributes of the concept are identified. Formation of model, borderline, and contrary cases exemplifies key characteristics. Antecedents, consequences, and empirical referents presented allow for further refinement of the key attributes defining the concept. Patient participation in nursing practice can be defined as an established relationship between nurse and patient, a surrendering of some power or control by the nurse, shared information and knowledge, and active engagement together in intellectual and/or physical activities.

TRAF4 is potently induced by TAp63 isoforms and localised according to differentiation in SCCHN.

p63, a member of the p53 family, is overexpressed in squamous cell carcinoma of the head and neck (SCCHN) and some other tumors of epithelial origin. As a transcription factor, p63 can bind to p53-type response elements and there is some overlap between p53 family transcriptional targets. Tumor necrosis factor receptor associated factor 4 (TRAF4) is a p53 regulated gene which is overexpressed in many human carcinomas. We investigated the involvement of p63 in regulation of TRAF4 and the expression of the TRAF4 protein in SCCHN. Disrupting endogenous p63 expression resulted in downregulation of TRAF4 mRNA and protein in an SCCHN cell line. Endogenous p63 bound to the TRAF4 promoter in vivo and reporter assays showed that p63, p73 and p53 can all transactivate TRAF4, with TAp63 isoforms being the most potent activators. The level of TRAF4 activation by TAp63 was two-fold higher than by p53, and TRAF4 was ten-fold more responsive to TAp63 than another p63-target, IGFBP3. Nuclear expression of TRAF4 was seen in normal oral epithelium and highly/moderately differentiated SCCHN, whereas cytoplasmic expression of TRAF4 was seen in poorly differentiated SCCHN. These results indicate that TRAF4 is a common target of p53 family members and that localization of TRAF4 is associated with differentiation of SCCHN cells.

Extraction and precipitation of chitosan from cell wall of zygomycetes fungi by dilute sulfuric acid.

A new method was developed in this work for extraction of chitosan from the zygomycetes cell wall. It is based on the temperature-dependent solubility of chitosan in dilute sulfuric acid. Chitin is soluble in neither cold nor hot dilute sulfuric acid. Similarly chitosan is not soluble at room temperature but is dissolved in 1% H 2SO 4 at 121 degrees C within 20 min. The new method was developed to measure the chitosan content of the biomass and cell wall. The procedures were investigated by measuring phosphate, protein, ash, glucuronic acid, and degree of acetylation. The cell wall derivatives of fungus Rhizomucor pusillus were then examined by this new method. The results indicated 8% of the biomass as chitosan. After treatment with NaOH, the alkali-insoluble material (AIM) contained 45.3% chitosan. Treatment of AIM with acetic acid resulted in 16.5% acetic-acid-soluble material (AcSM) and 79.0% alkali- and acid-insoluble material (AAIM). AcSM is usually cited as pure chitosan, but the new method shows major impurities by, for example, phosphate. Furthermore, AAIM is usually considered to be the chitosan-free fraction, whereas the new method shows more than 76% of the chitosan present in AIM is found in AAIM. It might indicate the inability of acetic acid to separate chitosan from the cell wall.

A comparison of experiences of training emergency care in military exercises and competences among conscript nurses with different levels of education.

The military emergency care education of nurses is primarily concerned with the treatment of soldiers with combat-related injuries. Even though great progress has been made in military medicine, there is still the pedagogical question of what emergency care education for military nurses should contain and how it should be taught. The aim of this study was to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education. A descriptive study was performed to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education in nursing. There were statistical differences between nurses with general nursing education and nurses with a general nursing education and supplementary education. A reasonable implication of the differences is that the curriculum must be designed differently depending on the educational background of the students. Hence, there is an interaction between background characteristics, e.g., the level of previous education and differences pertaining to clinical experience of the participants, and the impact of the exercise itself.

Patient participation in nursing care from a patient perspective: a Grounded Theory study.

UNLABELLED: the study's rationale: Patients' active participation in their own care is expected to contribute to increased motivation to improve their own condition, better treatment results and greater satisfaction with received care. Knowledge of patients' understanding of participation is of great importance for nurses in their efforts to meet patient expectations and for quality of nursing care. AIM: The aim was to explore the meaning of patient participation in nursing care from a patient point of view. METHODOLOGICAL DESIGN AND JUSTIFICATION: Six tape-recorded focus group interviews with 26 Swedish informants described opinions on and experiences of patient participation. The informants consisted of patients in somatic inpatient care as well as discharged patients from such a setting. The Grounded Theory method was used and the data were analysed using constant comparative analysis. ETHICAL ISSUES AND APPROVAL: The ethics of scientific work was followed. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study. FINDINGS: The patients emphasised the importance of collaboration to improve participation. The core category, Insight through consideration, was generated from four inter-related categories: (i) Obliging atmosphere; (ii) Emotional response; (iii) Concordance; and (iv) Rights and their 15 subcategories. CONCLUSIONS: The meaning structures of patient participation in nursing care revealed from a patient point of view, seemed to mainly consist of not only external factors presented by the institutions -- by the professionals -- but also internal patient factors. The patients' view of participation should be considered to a greater degree in nursing practice and education, as should also further development of nursing care policy programmes, evaluation and quality assurance criteria. For further development, studies are needed in similar and other settings.

The criteria nurses use in assessing acute trauma in military emergency care.

Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers' survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994-1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.

Strategies in caring for women with postpartum psychosis--an interview study with psychiatric nurses.

AIM AND OBJECTIVE: The aim of this study was to explore strategies in caring for women with postpartum psychosis used by nurses. BACKGROUND: The most serious type of psychiatric illness in connection with childbirth is postpartum psychosis. Nearly two in 1000 newly delivered women are stricken by postpartum psychosis. Most of these patients need psychiatric care to recover. While earlier studies point to the need for psychiatric care, knowledge of specific nursing strategies in caring for postpartum psychosis patients remains limited. METHODS: Interviews with 10 experienced psychiatric nurses were carried out, transcribed verbatim and an inductive content analysis was made. RESULT: The main strategies for care found in this study were: (i) To create a patient-nurse relationship and (ii) To apply nursing therapeutic interventions. Presence, continuity and nurse-patient partnership contributed to create a relationship and incorporate the rest of the care team. To satisfy the patients' basic needs and feeling of security was the foundation of the nursing therapeutic interventions. Confirmation and giving hope were also used as nursing therapeutics as well as information to the patient and her relatives about her illness. CONCLUSION: The conclusion of the study is that strategies used by nurses are a combination of general and psychiatric nursing approaches but the specificity in caring knowledge for caring patients with postpartum psychosis requires further development. RELEVANCE TO CLINICAL PRACTICE: The result of the study indicates that it is important to organize patient care for postpartum psychosis with continuity and consistency and to support the nurse to create a relationship and therapeutic intervention with the patient. The present study shows the importance of further developing specific nursing theories that can be applied when caring for patients with postpartum psychosis. It also shows the need for further pedagogical education for mental health nurses.

Quantification of the pain terms hurt, ache and pain among nursing students.

The aim of this study was to determine the quantitative meaning nursing students ascribe to the pain terms hurt (ont), ache (värk) and pain (smärta). In total, 549 nursing students filled in a questionnaire including questions about age, gender, and health care work experience. The students were also requested to rate response using a Visual Analogue Scale (VAS) rating for different statements about hurt, ache and pain. The results show that there were significant differences (p < 0.001) between rated intensity of the statements of hurt, ache and pain. There were, however, large variations in the students' ratings of the pain terms; hurt ranged from 3 to 97 mm, ache from 7 to 97 mm and pain from 27 to 100 mm. There were no significant differences between male and female students regarding their ratings of hurt and ache when they were used to describe the worst self-experienced pain. Female students rated their experience of pain significantly higher (p < 0.001) on the VAS compared with male students. There was no significant correlation between previous experience of health care work and rated intensity of hurt, ache and pain. In conclusion, this study shows that there exist significant differences between the pain terms hurt, ache and pain according to a rating on a VAS. However, the results also demonstrate that there are large individual variations in how the students quantify the fictitious patient statements of hurt, ache and pain.

Patient participation in nursing care: towards a concept clarification from a nurse perspective.

AIM: The aim of this study was to investigate the meanings of the concept of patient participation in nursing care from a nurse perspective. BACKGROUND: Participation is essential and increases patients' motivation and satisfaction with received care. Studies of patient participation in nursing care are not congruent regarding definition, elements and processes. This lack of clarity is amplified by several terms used; patient/client/consumer involvement or collaboration, partnership and influence. Despite the fact that several nursing theories have emphasized the importance of patient participation, an empirically grounded theory has yet to be published. METHODS: Seven focus group interviews were held with nurses providing inpatient physical care at five hospitals in West Sweden. The focus groups consisted of Registered Swedish nurses (n = 31) who described the meaning and implementation of patient participation in nursing care. A Grounded Theory approach has been applied to tape-recorded data. Constant comparative analysis was used and saturation was achieved. RESULTS: Mutuality in negotiation emerged as the core category for explaining nurses' perspectives on patient participation in nursing care. It is characterized by four interrelated sub-core categories: interpersonal procedure, therapeutic approach, focus on resources and opportunities for influence. Mutuality in negotiation constitutes the dynamic nurse-patient interaction process. CONCLUSIONS: The study clarifies that patient participation can be explained as an interactional process identified as mutuality in negotiation based on four components. RELEVANCE TO CLINICAL PRACTICE: The results are important and can be used in nursing practice and education. Application in a clinical context means nursing care organized to include all the components presented. The results can also be used in quality assurance to improve and evaluate patient participation.

Expression of p53 isoforms in squamous cell carcinoma of the head and neck.

Recent data indicate that, similar to p63 and p73, several different p53 isoforms can be produced in humans through alternative initiation of translation, usage of an internal promoter and alternative splicing. These isoforms are reported to have varying functions and expressions. In squamous cell carcinoma of the head and neck (SCCHN), disruption of the p53 pathway is one of the most common genetic alterations. However, to our knowledge, no studies regarding the expression of different p53 isoforms in SCCHN have so far been performed. We screened for the expression of different p53 isoforms in SCCHN and clinically normal oral epithelia using nested RT-PCR. p53 mRNA was expressed in all tumours, all matched clinically normal tissue adjacent to the tumour and in buccal mucosa from healthy volunteers. Of the novel isoforms, p53beta was detected in the majority of samples analysed, and all of the recently described isoforms were also detected in at least some tumour and normal epithelium samples, with the exception of Deltap53 isoforms. We conclude that p53 variant mRNAs are expressed in both normal oral stratified epithelium and SCCHN. Improvements in methodologies and reagents to detect and quantify p53 isoform expression in clinical material will be required to correlate p53 status with clinical outcomes.

Pain, psychological distress and health-related quality of life at baseline and 3 months after radical prostatectomy.

BACKGROUND: Inadequate management of postoperative pain is common, and postoperative pain is a risk factor for prolonged pain. In addition to medical and technical factors, psychological factors may also influence the experience of postoperative pain. METHODS: Pain was measured postoperatively at 24, 48, and 72 hr in hospital and after 3 months at home in 140 patients undergoing radical prostatectomy (RP). Patients answered questionnaires about anxiety and depression (HAD scale) and health-related quality of life (SF-36) at baseline and 3 months after surgery. RESULTS: In the first 3 postoperative days, mild pain was reported by 45 patients (32%), moderate pain by 64 (45%), and severe pain by 31 (22%) on one or more days. High postoperative pain scores were correlated with length of hospital stay and with high pain scores at home. Forty patients (29%) reported moderate (n = 35) or severe (n = 5) pain after discharge from hospital. Patients who experienced anxiety and depression preoperatively had higher postoperative pain scores and remained anxious and depressed 3 months after surgery. The scores for the physical domains in the SF-36 were decreased, while the mental health scores were increased at 3 months. Anxiety and depression were negatively correlated with all domains of the SF-36. CONCLUSION: There is a need for nurses to be aware of the psychological status of RP patients and its impact upon patients' experience of postoperative pain and recovery. The ability to identify patients with psychological distress and to target interventions is an important goal for future research.

Pain assessment in the perspective of action science.

Pain assessment is examined in the perspective of action science with the aim to discover espoused theories and theories-in-use for pain assessment. In action science there are 2 sets of theories of action: espouse theories and theories-in-use, which often exist in practice inconsistently with each other resulting in haphazard actions. Espoused theories of pain and pain assessment and a set of theories-in-use were revealed. Alignments between the espoused theories and the theories-in-use, and disparities between these theories were found in the pain assessment situations. The findings point to possible explanations regarding problems in pain assessment, and provide insights into our understanding of nursing practice especially in relation to pain assessment.

Decreased expression of p63 in oral lichen planus and graft-vs.-host disease associated with oral inflammation.

BACKGROUND: Oral lichen planus (OLP) and graft-vs.-host disease (GVHD) are conditions with increased risk of malignant transformation to squamous cell carcinoma of the head and neck (SCCHN). The p63 gene encodes six different proteins and is expressed at high levels in SCCHN. METHODS: Biopsies from patients diagnosed with OLP and GVHD were analysed for p63 protein expression using antibodies distinguishing between the major isoforms expressed in normal epithelia, in parallel with biopsies from normal buccal mucosa and SCCHN. RESULTS: In OLP and GVHD a decreased expression of all p63 isoforms was seen, while expression of p53 protein was upregulated, compared with normal mucosa. In SCCHN, p63 was abundantly expressed and some tumours showed strong p53 staining, suggestive of p53 mutation. CONCLUSIONS: Decreased p63 and increased p53 expression in OLP and GVHD indicates a coordinated action of these two related proteins to protect the oral mucosae from the damaging effects of underlying inflammation. In SCCHN disruption of the TP53 gene and overrepresentation of certain p63 isoforms has been seen, indicating that this could lead to neoplastic transformation.