Ex-situ liver resection for complex Echinococcus multilocularis infection: a case report.

Echinococcus multilocularis, the fox dwarf tapeworm, causes alveolar echinococcosis (AE), a critical and life-threatening condition. A radical surgical approach represents the only curative option. In this case study, we present a 37-year-old man diagnosed with extensive hepatic AE requiring ex-situ extended right-sided liver resection including the caudate lobe and retro-hepatic vena cava. The left liver segments were auto-transplanted with reconstruction of the left hepatic vein and an inferior vena cava graft. In the post-operative course, the patient developed a bile leak, which was successfully managed with endoscopic stent intervention. He was discharged after a three-week hospitalization. Medical treatment with albendazole was initiated preoperatively and continued postoperatively.

Comparing didactic approaches for practical skills learning in Scandinavian nursing simulation centres: A qualitative comparative study.

AIM: To explore and compare the didactic approaches to practical skills learning at simulation centres in Scandinavian universities and university colleges. BACKGROUND: Academic simulation centres are an important arena for learning practical nursing skills which are essential to ensure competent performance regarding patient safety and quality of care. Knowledge of didactic approaches to enhance learning is essential in promoting the provision and retention of students' practical nursing skills. However, research on didactical approaches to practical nursing skills learning is lacking. DESIGN: A qualitative comparative design was used. METHODS: During November and December 2019, interviews were conducted with a total of 37 simulation centre directors or assistant directors, each of whom possessed in-depth knowledge of practical skills in teaching and learning. They represented bachelor nursing education in Denmark, Norway and Sweden. A qualitative deductive content analysis was conducted. RESULTS: The results revealed all five predetermined didactical components derived from the didactical relationship model. Twenty-two corresponding categories that described a variation in didactic approaches to practical skills learning in Scandinavian nursing simulation centres were identified. The didactical components of Learning process revealed mostly similarities, Setting mostly differences and Assessment showed only differences in didactic approaches. CONCLUSION: Although various didactic approaches were described across the countries, no common approach was found. Nursing educational institutions are encouraged to cooperate in developing a shared understanding of how didactic approaches can enhance practical skills learning. IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE: Cross-country comparisons of practical nursing skills learning in Scandinavian countries highlight the importance of educator awareness concerning the impact diverse didactic approaches may have on competent performance in nursing education. Competent performance is pivotal for ensuring patient safety and the provision of high-quality care. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. REPORTING METHOD: This study followed the Consolidated Criteria for Reporting Qualitative Research reporting guidelines.

Individuals living with a liver transplant - a follow-up study exploring mental, emotional and existential issues 10 years after transplantation.

BACKGROUND: Going through a liver transplantation is by many recipients considered mentally and emotionally burdensome. AIM: The aim of this study was to explore individuals' mental, emotional and existential experiences living with a liver transplant during a period of approximately ten years. METHODOLOGICAL DESIGN: The methodology in this study is based on Gadamer's hermeneutics. Galvin and Todres' conceptual framework on well-being was applied in the interpretation process. RESEARCH METHODS: Both researchers conducted interviews, which took the form of conversations. We made use of Brinkmann and Kvales' three types of interpretation. ETHICAL ISSUES AND APPROVAL: The study was approved by the Ombudsman for Privacy of the Norwegian Social Data Services and is based on informed consent and confidentiality. RESULTS: Three themes emerged through interpretation: 1. From great suffering to gratitude and a humble attitude towards life. 2. From living in uncertainty to leading a normal life. 3. From hopelessness and anxiety to an indifferent attitude towards life. CONCLUSION: This study showed that the process of receiving a new liver and living with it, had changed most of the participants' attitudes towards life in a humble way. Some persons struggled with life and experienced depression anxiety, as well as lack of energy.

Clinical and biochemical impact of vitamin B6 deficiency in primary sclerosing cholangitis before and after liver transplantation.

BACKGROUND AND AIMS: We previously demonstrated that people with primary sclerosing cholangitis (PSC) had reduced gut microbial capacity to produce active vitamin B6 (pyridoxal 5'-phosphate [PLP]), which corresponded to lower circulating PLP levels and poor outcomes. Here, we define the extent and biochemical and clinical impact of vitamin B6 deficiency in people with PSC from several centers before and after liver transplantation (LT). METHODS: We used targeted liquid chromatography-tandem mass spectrometry to measure B6 vitamers and B6-related metabolic changes in blood from geographically distinct cross-sectional cohorts totaling 373 people with PSC and 100 healthy controls to expand on our earlier findings. Furthermore, we included a longitudinal PSC cohort (n = 158) sampled prior to and serially after LT, and cohorts of people with inflammatory bowel disease (IBD) without PSC (n = 51) or with primary biliary cholangitis (PBC) (n = 100), as disease controls. We used Cox regression to measure the added value of PLP to predict outcomes before and after LT. RESULTS: In different cohorts, 17-38% of people with PSC had PLP levels below the biochemical definition of a vitamin B6 deficiency. The deficiency was more pronounced in PSC than in IBD without PSC and PBC. Reduced PLP was associated with dysregulation of PLP-dependent pathways. The low B6 status largely persisted after LT. Low PLP independently predicted reduced LT-free survival in both non-transplanted people with PSC and in transplant recipients with recurrent disease. CONCLUSIONS: Low vitamin B6 status with associated metabolic dysregulation is a persistent feature of PSC. PLP was a strong prognostic biomarker for LT-free survival both in PSC and recurrent disease. Our findings suggest that vitamin B6 deficiency modifies the disease and provides a rationale for assessing B6 status and testing supplementation. IMPACT AND IMPLICATIONS: We previously found that people with PSC had reduced gut microbial potential to produce essential nutrients. Across several cohorts, we find that the majority of people with PSC are either vitamin B6 deficient or have a marginal deficiency, which remains prevalent even after liver transplantation. Low vitamin B6 levels strongly associate with reduced liver transplantation-free survival as well as deficits in biochemical pathways dependent on vitamin B6, suggesting that the deficiency has a clinical impact on the disease. The results provide a rationale for measuring vitamin B6 and to investigate whether vitamin B6 supplementation or modification of the gut microbial community can help improve outcomes for people with PSC.

Practice education facilitators perceptions and experiences of their role in the clinical learning environment for nursing students: a qualitative study.

BACKGROUND: Clinical placement is recognised as essential for nursing students' development of clinical competence. However, difficulties in providing supportive clinical learning environments are a well-known challenge in nursing education. In Norway, the use of nurse educators in joint university and clinical roles has been recommended as an initiative to strengthen the clinical learning environment and enhance the educational quality. In this study we use the term practice education facilitator in a generic sense for these roles. The aim of this study was to explore how practice education facilitators can contribute to strengthen the clinical learning environments for nursing students. METHODS: This study has a qualitative explorative design with a purposive sample of practice education facilitators affiliated to three different universities located in southeast, mid-, and northern Norway. Individual in-depth interviews with 12 participants were conducted during spring 2021. RESULTS: A thematic analysis resulted in four themes: "coherence between theory and practice"; "student support and guidance during placement"; "supporting the supervisors to support the students" and "factors influencing the practice education facilitators' performance in their role". The participants experienced that the practice education facilitator role contributed to strengthened clinical learning environments. However, their performance in the role was found to be contingent upon factors such as time allocated for the role, personal and professional attributes of the post holder, and a common understanding within the organisations regarding practice learning and role remits for the practice education facilitator. CONCLUSIONS: Findings indicate that the practice education facilitator role can be a valuable resource for clinical supervisors and nursing students in clinical placement. Moreover, nurse educators who are familiar with the clinical area, and who are insiders in both settings, are ideally placed to contribute to bridge the theory-practice gap. The benefits of using these roles, however, were influenced by personal attributes of the post holder, time allocated for the role and the number of practice education facilitators positions, and management anchorage. Thus, to achieve the full potential of these roles, efforts to reduce these barriers should be considered.

Influence of simulation and clinical settings on peripheral vein cannulation skill learning in nursing education: A qualitative study.

Background: Peripheral vein cannulation is a complex yet common practical skill. Learning to insert a peripheral vein cannula is fundamental in nursing education; however, the most beneficial pedagogical approaches are yet to be elucidated. Objective: To explore and impart a deeper understanding of the learning conditions in nursing education for developing competency in peripheral vein cannulation. Design: Qualitative, explorative. and comparative research design. Settings: Two nursing educational settings in southern Norway: an academic setting for simulation-based peripheral vein cannulation skill learning, followed by a hospital setting that provided a 9 week clinical placement period. Participants: Nine student nurses in the second year of a bachelor's programme in nursing. Methods: Focus group interviews, individual interviews, and ad hoc conversations with the student nurses on their experiences during and after the process of developing competency in peripheral vein cannulation. Thematic analysis was used to identify categories and common themes. Results: Eight major themes were identified: 'Anatomical and physiological conditions related to the training modalities', 'Realism in training', 'Sequences in peripheral vein cannulation training', 'Different training modalities affording varied learning opportunities', 'Professional nursing assessments', 'Patients' and peers' emotional reactions', 'Student nurses' own emotional reactions', and 'Significance of the relationship between the student nurse and patient'. Conclusions: Simulation-based peripheral vein cannulation practice was an important starting point for the students' skill learning. However, the students experienced the complexity of the skill only in the clinical setting because it offered several learning opportunities. Nonetheless, our findings indicate a need to further review peripheral vein cannulation skill learning, especially patient contributing factors, to enhance the transfer of learning from the simulation setting to the clinical setting. Tweetable abstract: Clinical setting-based peripheral vein cannulation practice is vital for student nurses' skill learning because of the skill's complexity.

The use of practice education facilitators to strengthen the clinical learning environment for nursing students: A realist review.

BACKGROUND: Research suggests that the interventions of practice education facilitators, who liaise between the higher education institution and the clinical placement sites, may strengthen the clinical learning environment for nursing students. However, there is a lack of evidence concerning the value of these roles in nursing education. OBJECTIVE: The objective of this study was to explore how, under what circumstances and why the practice education facilitator role can strengthen the clinical learning environment for nursing students. DESIGN: A realist review was conducted to understand the contextual factors and mechanisms that support or hinder the capacity of the practice education facilitator to strengthen the clinical learning environment for nursing students. SETTING: The settings are clinical areas where nursing students are directly involved with patient care. PARTICIPANTS: The participants comprised academic and clinical staff involved in clinical nursing education. METHODS: This realist review was conducted in three overlapping and iterative phases: (1) the development of an initial programme theory explaining how the practice education facilitator role is thought to strengthen the clinical learning environment; (2) structured searches, screening and data extraction; and (3) analysis and synthesis to develop and refine the programme theory. RESULTS: The review included 27 research papers. Evidence from these studies led to the development of five context-mechanism-outcome configurations that explain how, under what circumstances and why practice education facilitators can (or can fail to) strengthen the clinical learning environment. Factors such as practice education facilitators' visibility and accessibility in the clinical area and their clinical credibility were found to influence whether clinical supervisors took the opportunity to seek support and guidance from them. Moreover, ward culture regarding student learning and opportunities to prepare for the role were found to influence clinical supervisors' motivation to carry out the functions of the role and develop professionally; this in turn further influenced whether they used the resources provided by the practice education facilitator. CONCLUSIONS: Theory-based explanations of how, under what circumstances and why the practice education facilitator role may strengthen the clinical learning environment of nursing students may support further development of this role in the future.

Learning practical nursing skills in simulation centers - A narrative review.

Background: Practical skills are complex procedures integrating communication and caring, as well as technical and manual aspects. Simulation at a simulation/skills center offers a wide range of learning activities and aims to imitate patient situations. Objectives: To investigate the international research literature on practical skills learning in simulation/skills centers in nursing education. Research questions: 1. What are the range and type of practical skills studied? 2. What learning activities are focused on in the studies included in the review? 3. What are the learning outcomes and how are they assessed? Design: Narrative review. Methods: We searched electronically and included studies from Medline Ovid, CINAHL, Eric, Embase, Academic Search Premiere, and Cochrane. Unique indexing terms and search strategies were developed for each database. The criteria for inclusion were bachelor nursing students as the study population and practical nursing skills learning in simulation/skills centers. We used Rayyan QCRIt for the initial screening and the Mixed Method Appraisal Tool for quality assessment. We used a narrative approach to synthesize the diverse range of studies. Findings: One hundred and twenty-one studies from 26 countries published between January 2013 and March 2022 were included. The amount of quantitative research was overwhelming (n = 108). A total of 50 different practical skills were represented. The studies focused on which learning modalities resulted in the best learning outcomes. Only 8.5% (n = 7) of the included studies concerned students' learning processes. Skill performance (n = 101), knowledge (n = 57), confidence (n = 34), and satisfaction (n = 32) were the main learning outcomes measured. Discussion: The quality assessment indicated that 10 of the studies achieved 100% on the mixed method appraisal tool criteria. In many of the studies with quasi-experimental and randomized controlled trial designs, the intervention group received some form of educational treatment while the control group received no treatment. The choice of no treatment for the control group in pedagogical research seems to disregard the inherent purpose and effect of teaching and learning. Conclusion: Heterogeneity in the use of learning modalities and measuring instruments precludes the possibility of building on other research. Technical skills were the preferred choice of skill, while skills that involved a fair measure of communication and collaboration were only sparingly studied. Students' learning processes were barely touched on in the included studies. More focus should be placed on this area in further research, since the choice of learning modalities may affect the students' learning processes in significant ways.

Fluctuating biomarkers in primary sclerosing cholangitis: A longitudinal comparison of alkaline phosphatase, liver stiffness, and ELF.

BACKGROUND & AIMS: Primary sclerosing cholangitis (PSC) is a progressive liver disease characterised by fluctuating liver biochemistries and highly variable disease progression. The Enhanced Liver Fibrosis (ELF®) test and liver stiffness measurements (LSMs) reflect fibrosis and predict clinical outcomes in PSC; however, longitudinal assessments are missing. We aimed to characterise the systematic change in ELF and LSM over time in a prospective cohort of patients with PSC, along with their longitudinal relationship to alkaline phosphatase (ALP) and bilirubin. METHODS: We included 113 non-transplant PSC patients (86 males [76.1%]; mean age 43.3 ± 15.7 years) with annual study visits between 2013 and 2019 at 2 Norwegian centres. ELF test, LSM, clinical data, liver biochemistries, and revised Mayo risk score were measured. We used linear mixed-effects models to estimate change over time, intraclass correlations (ICCs), and their relationship with ALP and bilirubin. RESULTS: At baseline, the median (range) ELF test was 9.3 (7.5-12.9) and median LSM 1.26 m/s (0.66-3.04 m/s). ELF and LSM increased over time (0.09 point/year, 95% CI [0.03, 0.15], p = 0.005, vs. 0.12 point/year, 95% CI [0.03, 0.21], p = 0.009). Between-patient effects explained 78% of ELF variation (ICC 0.78) and 56% of LSM variation (ICC 0.56). ALP also increased and showed the highest ICC (0.86). CONCLUSIONS: ELF and LSM increased over a 5-year period. Longitudinal analyses demonstrated differences regarding within- and between-patient effects, suggesting that the ELF test may have superior reliability for risk stratification compared with LSM in PSC. LAY SUMMARY: Primary sclerosing cholangitis (PSC) is characterised by substantial disease variability between patients and fluctuating liver biochemistries. Hence, new biomarkers are needed to identify individuals with an increased risk of developing end-stage liver disease. We explore the change over time of 2 putative prognostic biomarkers in PSC, the serum Enhanced Liver Fibrosis (ELF®) test and LSMs by ultrasound, demonstrating differences that may reflect differing abilities to discriminate risk.

Development and Testing of an Instrument for Summative Assessment of Practical Skill Performance: A Generalizability Theory Approach.

BACKGROUND AND PURPOSE: Many newly graduated nurses lack proficiency in practical skill performance. Presently, nursing students' practical skill is assessed by summative instruments with overarching items. The purpose of this study was to develop a more detailed instrument to use in summative assessment of nursing students' practical skill performance and to assess its psychometric properties. METHODS: A 50-item instrument was developed. Video-recorded performances were rated by experienced clinical supervisors. A multifacet measurement design was developed. Relevant parameters were estimated by generalizability analysis. RESULTS: Findings indicated that error of measurement were mainly caused by raters far more than by items. CONCLUSIONS: The present study suggested that summative assessment in realistic settings may not apply one rater only. Two to three/four raters appear necessary to dependably measure most skills.

Health care provider's responses to children's resistance to peripheral vein cannulation: A qualitative observational study.

AIMS AND OBJECTIVES: Health care and treatment should be voluntary, but restraint is often used during treatment of children. Knowledge about how health care providers respond to preschool children's resistance is lacking and can help understand current paediatric care in hospitals. The aim of the present article was to provide knowledge about how healthcare providers respond to preschool children's resistance during the clinical procedure of peripheral vein cannulation. DESIGN: An explorative qualitative research design was developed for this study. METHODS: Observations with video recording were used to collect data. Eight nurses and seven physicians participated in the study (n = 15). Their responses to preschool children's (n = 6) resistance were studied during 14 attempts of peripheral vein cannulation. Consolidated criteria for reporting qualitative research (COREQ) were used. RESULTS: The healthcare providers made 380 responses to children's resistive expressions, interpreted within four main types, responses to acknowledge the child, responses to distract the child, responses to persuade the child and responses to reject the child. All main types of responses were used by both nurses and physicians. Regardless of the amount of resistance the children expressed, all children received distracting and acknowledging responses. Rejecting responses were used approximately twice as much in the implementation phase as in the preparation phase. Distraction, persuasion and rejection began in the preparation phase and increased in the implementation phase. CONCLUSIONS: The main types and sub-types of responses showed how healthcare providers use a wide array of responses to meet children's resistance during peripheral vein cannulation. RELEVANCE TO CLINICAL PRACTICE: The results can enable health care providers to become aware of their own practices during peripheral vein cannulation and other clinical procedures and to elaborate on their use of responses that can be considered intrinsically less child-friendly.

Medical Complications of Anorexia Nervosa.

OBJECTIVE: The purpose of this study was to describe the medical complications of anorexia nervosa (AN) to enable a consult-liaison psychiatrist to be familiar with these complications when involved with the care of a hospitalized patient with AN. METHODS: Comprehensive PubMed search of English language publications of adult patients with AN was carried out using keywords, phrases, and medical subject headings of anorexia nervosa-medical complications, cardiac, osteoporosis, gastrointestinal, hematological, and endocrine. The database search was restricted by time of publication of studies from 2005 to 2020. RESULTS: Every organ system can be adversely affected by AN. Most are fully reversible with time and informed medical care. A multidisciplinary team is needed to optimally care for patients who are hospitalized as a result of the medical complications of their AN. CONCLUSIONS: Consult-liaison psychiatrists are asked to help in the care of patients with AN who are admitted to a hospital because of a medical complication of their illness. Being familiar with these complications and their treatments will optimize their hospital stays and the care provided. In addition, involving other relevant ancillary services is an important care consideration.

"Please mind the gap": A secondary analysis of discomfort and comfort in intensive care.

AIMS AND OBJECTIVES: To explore in depth discomfort in intensive care as experienced by patients and attended to by critical care nurses. BACKGROUND: Discomfort in illness is complex and persistent, and its alleviation is a challenge for nurses working in intensive care units (ICU). In previous studies, we showed that ICU patients described little actual pain but suffer from much discomfort. Critical care nurses had a systematic approach to the treatment of pain, but were more haphazard in dealing with other types of discomfort. DESIGN: Secondary qualitative analysis of data from two previous exploratory studies. METHODS: Content analysis was used on existing data from 28 interviews with ICU patients, and 16 field notes and interviews with critical care nurses. Kolcaba's Comfort Theory was applied for further analysis. The COREQ checklist was used. RESULTS: Three themes, "Being deprived of a functioning body", "Being deprived of a functioning mind" and "Being deprived of integrity" characterised the discomfort experienced by ICU patients. The nurses appeared to attend to all areas of discomfort expressed by patients. In need of, and providing acknowledgment and alleviation became a common overarching theme. We identified a comfort gap caused by the discrepancy between the patients' needs and the nurses' achievements in fulfilling these needs. CONCLUSIONS: A gap exists between ICU patients' comfort needs and nurses' achievements in fulfilling these, indicating that discomfort currently is an inevitable part of the critical illness trajectory. Increased knowledge about how the brain is affected in ICU patients and more systematic approaches to assessing comfort needs and enhancing comfort may support nurses in fulfilling patient needs and possibly diminish the existing comfort gap. RELEVANCE FOR CLINICAL PRACTICE: An increased understanding of the complex experience of discomfort in ICU patients may bring about more systematic approaches to enhance comfort and direct for education and further research.

Comparing Nursing Student Competence in CPR before and after a Pedagogical Intervention.

Nursing students must be able to initiate and perform effective cardiopulmonary resuscitation (CPR) when they start their career in nursing. Studies show that students' competency in CPR is deficient, indicating that better training is necessary during nursing education. This study reports on the differences in nursing students' competence in CPR before and after a longitudinal pedagogical intervention across the curriculum. Changes in the curriculum were relocation and added testing of CPR skills, inclusion of a course in defibrillation, a knowledge test as stimuli before simulation, and more simulation practice with deteriorating patients. This was a comparative study between two cohorts of students in the bachelor in nursing education. We measured knowledge and compression performance in the students' final year of education. Students in cohort 2, who received the pedagogical intervention, had a significant higher total knowledge score than students in cohort 1. Students' mean depth and number of correct compressions was similar. Students in cohort 2 had a significantly higher mean rate of compressions, number of compressions per minute, and mean number of compressions with incorrect hand positions. Although the new curriculum afforded more hands-on practice of CPR, it was not enough to improve the students' performance to match the demands set out in national and international guidelines.

Improving Clinical Nurses' Development of Supervision Skills through an Action Learning Approach.

The aim of this study was to investigate action learning as an implementation method in a large-scale project with many participants in several autonomous and geographically spread groups. The focus of the implementation was the Model of Practical Skill Performance as a learning and supervision tool in the clinical education of nursing students. Nineteen action learning groups were established, and a total of 129 clinical supervisors and 13 facilitators were involved. To evaluate the implementation process, qualitative data were generated through three focus group interviews, questionnaires, and notes. Data illuminate clinical supervisors' perceptions of value, impact, and sustainability when they participate in an action learning group to become familiar with the Model of Practical Skill Performance. The deductive data analysis was guided by central concepts from action learning. Action learning proved to be an engaging and effective tool in the implementation where the main strength seemed to be the autonomous local group supporting collective reflections on actions. Clinical supervisors had the right competences to adopt a reflective process-oriented approach, which is the hallmark of action learning. This study shows the necessity of collaboration between stakeholders in practice, education, and management to implement large-scale projects in clinical practice. The findings imply that managers should choose participants on the basis of their motivation and their voluntary wish to participate and that nurses' immersion in the project over time aids implementation.

"Having the compass-drawing the map": Exploring nurses' management of pain and other discomforts during use of analgosedation in intensive care.

AIM: To explore the deliberation and enactment processes of nurses in relation to pain and other discomforts in the critically ill patients after the implementation of an analgosedation protocol. BACKGROUND: Nurses in intensive care units (ICU) face great challenges when managing pain and other discomforts and distinguishing between patients' needs for analgesics and sedatives. An analgosedation protocol favouring pain management, light sedation and early mobilization was implemented in a university hospital ICU in Norway in 2014. Changing sedation paradigms resulting in an increasing number of awake patients during critical illness is expected to affect nursing practice. DESIGN: Exploratory, single-unit study in a mixed adult ICU. METHODS: Data collection with participant observation and semi-structured interviews in sixteen clinical situations in 2014 and 2015. Thirteen experienced certified critical care nurses were included. Thematic content analysis was conducted. RESULTS: An overall theme "Having the compass-drawing the map" emerged from the analysis. The protocol or strategy of analgosedation appeared to provide a direction for treatment and care, although requiring extensive interpretation of needs and individualization of care, often in challenging situations. The overall theme was abstracted from three themes: "Interpreting a complex whole," "Balancing conflicting goals" and "Experiencing strain from acting across ideals." CONCLUSION: Nurses seem to attend adequately to patient pain, but the approach to discomforts other than pain appears unsystematic and haphazard. More explicit goals of care and strategies to handle discomfort as distinct from pain are needed. More research is needed to identify effective comfort measures for ICU patients.

Stillbirth and factor V Leiden - A regional based prospective evaluation.

BACKGROUND: Approximately 10% of Swedes are carriers of coagulation factor V Leiden (FVL). It has been suggested that carriers are at an increased risk of stillbirth. We aimed to assess the risk of stillbirth in carriers of FVL as compared to non-carriers. METHODS: A consecutive registration of all stillbirths from 2001 to 2015 in the whole Stockholm region has been performed. A FVL blood sample, an autopsy and histopathological examination of the placenta was scheduled to be offered all women with stillbirth. Main outcome was the difference in carriership of FVL between cases with live- vs. stillbirth. The primary cause of death was determined according to the Stockholm hierarchical classification of stillbirth. RESULTS: The incidence of stillbirth was 3.6‰. Out of the 1392 cases of stillbirth occurring during the study period, FVL status was determined in 963 women. Of these 74 (7.7%) were carriers of FVL as compared to 8.1% in the control group (p = 0.6). A primary cause of death due to infection was twice as common among non-carriers compared to carriers of FVL (odds ratio [OR] = 2.3, 95% CI 1.08-4.8). In the whole study group, the prevalence of SGA was 14-fold increased among stillbirths as compared to live births (OR = 13.9, 95% CI 12.4-15.6). CONCLUSION: Maternal FVL carriership was not related to an increased risk of stillbirth. However, a diagnosis of primary cause of death due to infection was less likely among FVL carriers.

The Impact of a New Pedagogical Intervention on Nursing Students' Knowledge Acquisition in Simulation-Based Learning: A Quasi-Experimental Study.

Simulation-based learning is an effective technique for teaching nursing students' skills and knowledge related to patient deterioration. This study examined students' acquisition of theoretical knowledge about symptoms, pathophysiology, and nursing actions after implementing an educational intervention during simulation-based learning. A quasi-experimental study compared theoretical knowledge among two groups of students before and after implementation of the intervention. The intervention introduced the following new components to the existing technique: a knowledge test prior to the simulation, video-recording of the performance, and introduction of a structured observation form used by students and facilitator during observation and debriefing. The intervention group had significantly higher scores on a knowledge test conducted after the simulations in comparison to the scores in the control group. In both groups scores were highest on knowledge of symptoms and lowest on knowledge of pathophysiology; the intervention group had significantly higher scores than the control group on both topics. Students' theoretical knowledge of patient deterioration may be enhanced by improving the students' prerequisites for learning and by strengthening debriefing after simulation.

"But Perhaps they could Reduce the Suffering?" Parents' Ambivalence toward Participating in Forced Peripheral Vein Cannulation Performed on their Preschool-Aged Children.

PURPOSE: The purpose of this study was to provide a better understanding of how parents experience the use of restraint during the performance of peripheral vein cannulation (PVC) on their child. DESIGN/METHODS: Qualitative, semi-structured interviews were performed with seven parents and one close relative who had accompanied their 3-5-year-old child while the child resisted the medical procedure of PVC. The analysis was guided by symbolic interactionism and resulted in two themes. RESULTS: The first theme that emerged, "Negotiating What Quality of Performance Should be Expected", was based on 1) Parents expected child-friendly encounters, 2) Performance of PVC caused unexpected and unnecessary suffering for the child, and 3) Parents explained and excused the performance of PVC. The second theme: "Negotiating One's Own Role and Participation in a Child's Suffering During the Procedure", was based on 1) Parents desired to be acknowledged and approached for suggestions regarding ways to ease the trauma surrounding the procedure, 2) Parents expressed uncertainty regarding the consequences that the procedure would have for the children, and 3) Parents desired to play a protective role, and they tended to engage in self-criticism. CONCLUSION: When the PVC was less child-friendly, poorly planned and chaotic or performed with lacking skills, the parents became unwilling partners in the unnecessary suffering of the child. A practical implication is that if pediatric health care providers are aiming for the reduction of restraint, they must better understand parents' expectations and experiences and ensure that the use of restraint is used as the last resort.