We need to talk: a qualitative inquiry into pathways to care for young men at ultra-high risk for psychosis.

Introduction: It is known from the literature that men are slower to seek help and staying engaged in mental health care compared to women. Seeing that in psychosis, men more often than women have insidious onsets but also a more malign illness course, it is important to find ways to improve timely help-seeking. The aim of this study was to explore barriers and facilitators for help-seeking in young male persons struggling with early signs of psychosis. Methods: Qualitative interviews with nine young men who suffer from a first episode of psychosis or psychosis risk symptoms. Results: Male stereotypical ideals, significant others, and knowledge of symptoms and where to get help as well characteristics of symptom trajectories appeared to be important determinants of help-seeking behavior. Discussion: Interviews indicated that help-seeking in the participants was delayed first, because of reluctancy to disclose distress and second, because significant others were unable to accurately recognize symptoms. Information, awareness, and easy access to care remain important in early detection and intervention in psychosis and psychosis risk. However, more emphasis should be placed on de-stigmatizing mental health problems in men and aiming information specifically at them.

Retinal surgery quality indicators for uncomplicated primary rhegmatogenous retinal detachment without a national registry.

PURPOSE: The objective of this study was to evaluate the possibility of analysing quality indicators for uncomplicated primary rhegmatogenous retinal detachment in a hospital department of ophthalmology without the support of a national registry or need to collect data from referring ophthalmological centres. METHODS: In 2014, we operated 231 consecutive eyes with uncomplicated retinal detachment. Our quality indicators were primary anatomical success, final anatomical success and postoperative endophthalmitis. We reviewed medical records in our university surgical department retrospectively and compared them with medical records from the regional hospitals that had referred most of the operated patients and done their own postoperative examination. Our hypothesis was that any retinal re-detachment and/or serious postoperative complication would be reported back. RESULTS: The medical records at the surgical department revealed primary anatomic success for 91.3% of eyes and final anatomical success of 99.6%. The data from the regional hospitals confirmed that our hypothesis was correct. All patients with adverse outcomes were referred back for reoperation. Patients who were not referred again had an attached retina and showed no signs of endophthalmitis. CONCLUSION: Our hypothesis that data in the surgical department's medical records would closely reflect those in referring hospitals was borne out. This supports, under current conditions, an effective strategy for analysing chosen quality indicators without relying on a national registry or reviewing records from regional hospitals.

How Supervisees on a Foundation Course in CBT Perceive a Supervision Session and what they Bring Forward to the Next Therapy Session.

BACKGROUND: There is limited research into the effect of supervision in cognitive behavioural therapy (CBT) from the supervisees' perspective. AIMS: The aim of the study was to acquire knowledge from the supervisees' perspective as to what in particular in the supervision process contributes to the therapy process. METHOD: Fourteen supervisees on a foundation course participated in the study. A qualitative approach was used with thematic analysis of the participants' written diaries after supervision and therapy sessions. RESULTS: Analyses of supervisees' experiences suggested that a variety of therapeutic interventions were easier to implement if one had the supervisor's support and felt free to decide if and when the suggested interventions could best be implemented. Evaluation in the form of positive feedback from the supervisor indicating that the supervisee was 'doing the right thing' was perceived to be important. A unifying theme when supervisees felt they were not getting anything out of the supervision was that the supervisees did not have a supervision question. CONCLUSIONS: The results of this research suggest that the supervisor's support during training is perceived to be important for the supervisee. Receiving positive feedback from one's supervisor in an evaluation is perceived to have a great impact on whether the therapist implements the suggested therapeutic interventions discussed in the previous supervision.

Phase Formation Behavior in Ultrathin Iron Oxide.

Nanostructured iron oxides, and especially hematite, are interesting for a wide range of applications ranging from gas sensors to renewable solar hydrogen production. A promising method for deposition of low-dimensional films is atomic layer deposition (ALD). Although a potent technique, ALD of ultrathin films is critically sensitive to the substrate and temperature conditions where initial formation of islands and crystallites influences the properties of the films. In this work, deposition at the border of the ALD window forming a hybrid ALD/pulsed CVD (pCVD) deposition is utilized to obtain a deposition less sensitive to the substrate. A thorough analysis of iron oxide phases formation on two different substrates, Si(100) and SiO2, was performed. Films between 3 and 50 nm were deposited and analyzed with diffraction techniques, high-resolution Raman spectroscopy, and optical spectroscopy. Below 10 nm nominal film thickness, island formation and phase dependent particle crystallization impose constraints for deposition of phase pure iron oxides on non-lattice-matching substrates. Films between 10 and 20 nm thickness on SiO2 could effectively be recrystallized into hematite whereas for the corresponding films on Si(100), no recrystallization occurred. For films thicker than 20 nm, phase pure hematite can be formed directly with ALD/pCVD with very low influence of the substrate on either Si or SiO2. For more lattice matched substrates such as SnO2:F, Raman spectroscopy indicated formation of the hematite phase already for films with 3 nm nominal thickness and clearly for 6 nm films. Analysis of the optical properties corroborated the analysis and showed a quantum confined blue-shift of the absorption edge for the thinnest films.

Complexity complicates lean: lessons from seven emergency services.

PURPOSE: The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data. DESIGN/METHODOLOGY/APPROACH: A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services' capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews. FINDINGS: The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity. ORIGINALITY/VALUE: The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.

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

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

Detection of recombinant human EPO administered to horses using MAIIA lateral flow isoform test.

Doping of horses with recombinant human erythropoietin (rHuEPO) to illegally enhance their endurance capacity in horseracing has been reported during the last years. This leads to increased blood viscosity which can result in sudden death and is of concern for the horse welfare. Additionally, the horse can start production of rHuEPO antibodies, which cross-reacts with endogenous equine EPO and can lead to severe anaemia and even death. In this study, a novel micro-chromatographic method, EPO WGA MAIIA, has been tested for the capability in plasma and urine samples to detect administration of erythropoiesis-stimulating agents, like the rHuEPO glycoprotein varieties Eprex and Aranesp, to horses. After administration of 40 IU Eprex kg(-1) day(-1) to seven horses during 6 days, the presence of Eprex in horse plasma was detected up to 2-5 days after last injection. In urine samples collected from two horses, Eprex was detected up to 3 days. A single injection of Aranesp (0.39 µg/kg) was detected up to 9 days in plasma and up to 8 days, the last day of testing, in the urine sample. The LC-FAIMS-MS/MS system, with 1 day reporting time, confirmed the presence of Eprex up to 1 day after last injection for six out of seven horses and the presence of Aranesp up to 5 days after last injection in plasma samples. The MAIIA system showed to be a promising tool with high sensitivity and extremely short reporting time (1 h).

Rapid detection of erythropoiesis-stimulating agents in urine and serum.

A rapid and easy-to-use test kit, EPO WGA MAIIA, which can be used for distinguishing various endogenous human erythropoietins (hEPOs) and several recombinant hEPO and EPO analogues, has been evaluated. The test is based on chromatographic separation of the glycosylated isoforms of EPO using wheat germ agglutinin (WGA) and a sensitive immunoassay using anti-EPO carbon black nanostrings and image scanning for quantification. All of the reactions take place along the porous layer of a lateral flow microcolumn containing WGA and anti-EPO zones. The presence of molecules resembling hEPOs, such as Mircera, was detected by the aberrant affinity interaction with the antibody zone on the strip. It was possible to distinguish nine recombinant hEPOs expressed in hamster and human cell lines, as well as Aranesp and Mircera, from endogenous urine hEPO. The required amount of EPO in the samples, a few picograms, is very low compared with other methods for EPO isoform identification. This EPO isoform determination method opens the possibility to monitor recombinant EPO therapy for clinical research and seems to be a valuable candidate to the arsenal of EPO doping control tests.

What happened to the no-wait hospital? A case study of implementation of operational plans for reduced waits.

BACKGROUND: Both research and practice show that waiting lists are hard to reduce. Implementing complex interventions for reduced waits is an intricate and challenging process that requires special attention for surrounding factors helping and hindering the implementation. This article reports a case study of a hospital implementation of operational plans for reduced waits, with an emphasis on the process of change. METHODS: A case study research design, theoretically informed by the Pettigrew and Whipp model of strategic change, was applied. Data were gathered from individual and focus group interviews with informants from different organizational levels at different times and from documents and plans. FINDINGS: The findings revealed arrangements both helping and hindering the implementation work. Helping factors were the hospital's contemporary savings requirements and experiences from similar change initiatives. Those hindering the actions to plan and agree the changes were unclear support functions and unclear task prioritization. CONCLUSIONS AND PRACTICE IMPLICATIONS: One contribution of this study is to demonstrate the advantages, disadvantages, and challenges of a contextualized case study for increased understanding of factors influencing organizational change implementation. One lesson for current policy is to regard context factors that are critical for successful implementation.

Longterm follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes and patient satisfaction.

PURPOSE: Floaters caused by degenerative or postoperative changes in the vitreous can interfere with all aspects of visual functioning. The aim of this study is to report the longterm outcome of pars plana vitrectomy (PPV) for persistent vitreous opacities. METHODS: In a retrospective, non-randomized, interventional case study we reviewed all cases of vitreous floaters that were vitrectomized at our department between 1997 and 2006. Patient complaints and satisfaction were assessed by a questionnaire administered at the end of follow-up. RESULTS: Seventy-three consecutive cases were included (61 patients). Mean Snellen best corrected visual acuity (BCVA) before surgery was 0.81. Overall, 85% of patients complained of severe or very severe difficulty caused by floaters. A total of 42% of eyes were pseudophakic, four of which were operated with combined PPV and phacoemulsification. Mean follow-up time was 37 months. Of the phakic eyes, 60% were operated for cataract during follow-up. One retinal detachment (RD) occurred immediately postoperatively (1.3%) and another four eyes developed RD during longterm follow-up 24-44 months after PPV (5.5% of cases). Postoperative BCVA remained mostly unchanged. Overall, 88% of patients were satisfied with the results of the operation. CONCLUSIONS: Some patients make considerable complaints as a result of vitreous opacities and their distress does not correlate with visual acuity. Vitrectomy is a safe and effective procedure with which to help these patients. Patients should be informed about the risk of cataract progression, unexpected inflammatory reaction and an increased risk for RD several years after PPV (5.5%).

Searching for recognition: the professional development of psychodynamic psychotherapists during training and the first few years after it.

The aim of the present study was to investigate the development of psychotherapists' professional self during training and the first few years after it. Constant comparison analysis was conducted on interviews with former students (N = 18) at a training institute for psychoanalytic psychotherapy. The resulting core category "searching for recognition" indicated that participants' ambition during the studied time period was to reach high status by becoming psychotherapists. During training, this was expressed by the category "attachment to preformed professional self," meaning that students wanted their preconceptions about therapy to be acknowledged by teachers. After training, participants experienced achieved recognition and, as a result, a sense of freedom to use their own judgment.

Rapid affinity purification of erythropoietin from biological samples using disposable monoliths.

Identification of post-translational modifications of proteins in biological samples often requires access to preanalytical purification and concentration methods. In the purification step high or low molecular weight substances can be removed by size exclusion filters, and high abundant proteins can be removed, or low abundant proteins can be enriched, by specific capturing tools. In this paper is described the experience and results obtained with a recently emerged and easy-to-use affinity purification kit for enrichment of the low amounts of EPO found in urine and plasma specimens. The kit can be used as a pre-step in the EPO doping control procedure, as an alternative to the commonly used ultrafiltration, for detecting aberrantly glycosylated isoforms. The commercially available affinity purification kit contains small disposable anti-EPO monolith columns (6 µL volume, Ø7 mm, length 0.15 mm) together with all required buffers. A 24-channel vacuum manifold was used for simultaneous processing of samples. The column concentrated EPO from 20 mL urine down to 55 µL eluate with a concentration factor of 240 times, while roughly 99.7% of non-relevant urine proteins were removed. The recoveries of Neorecormon (epoetin beta), and the EPO analogues Aranesp and Mircera applied to buffer were high, 76%, 67% and 57%, respectively. The recovery of endogenous EPO from human urine was 65%. High recoveries were also obtained when purifying human, mouse and equine EPO from serum, and human EPO from cerebrospinal fluid. Evaluation with the accredited EPO doping control method based on isoelectric focusing (IEF) showed that the affinity purification procedure did not change the isoform distribution for rhEPO, Aranesp, Mircera or endogenous EPO. The kit should be particularly useful for applications in which it is essential to avoid carry-over effects, a problem commonly encountered with conventional particle-based affinity columns. The encouraging results with EPO propose that similar affinity monoliths, with the appropriate antibodies, should constitute useful tools for general applications in sample preparation, not only for doping control of EPO and other hormones such as growth hormone and insulin but also for the study of post-translational modifications of other low abundance proteins in biological and clinical research, and for sample preparation prior to in vitro diagnostics.

Interactions between human neutrophils and mucin-coated surfaces.

Recently, we showed microscopically that bovine (BSM), porcine (PGM) and human (MG1) mucin coatings could suppress the adhesion of neutrophils to a polyethylene terephthalate-based model biomaterial (Thermanox). Here, using the release of reactive oxygen species (ROS) as a marker of material-induced neutrophil activation, the strong surface-passivating effects of these mucin coatings were corroborated. Under optimal adsorption conditions, all mucin species performed equally well, thus indicating a high degree of functional homology between the mucins. Cell adhesion and morphology correlated well with the release of ROS. Quartz crystal microbalance (QCM-D) analysis linked low neutrophil activation to efficient mucin surface-shielding. Interestingly, the shielding power appeared equal for thick expanded and thin compact mucin coatings. Combined mucin-serum coatings were found to be highly surface-passivating. Particularly, since our data suggested partly synergistic mucin-serum action, we highlight the possibility that pre-adsorbed mucins could provide favorable support for adsorbing host components.

Potential use of mucins as biomaterial coatings. II. Mucin coatings affect the conformation and neutrophil-activating properties of adsorbed host proteins--toward a mucosal mimic.

In continuation of our recent fractionation and characterization study on mucins of bovine salivary (BSM), porcine gastric (PGM), and human salivary (MG1) origin, this study evaluates the effect of mucin precoating on the conformation and neutrophil-activating properties of host proteins adsorbed to a polyethylene terephthalate-based model biomaterial. Microscopy combined with assays for the neutrophil releases of reactive oxygen species and human neutrophil lipocalin showed that mucin precoating greatly reduced the strong immune-response normally induced by adsorbed immunoglobulin G (IgG) and secretory immunoglobulin A (sIgA), respectively. A similar finding was made for the proinflammatory fibrinogen. Although the total uptakes of these proteins depended on the mucin surface concentration, a detailed composite analysis suggested the fraction of surface-exposed protein to be a stronger determinant of coating performance. The unexpectedly low neutrophil activation showed by composites containing near-monolayer concentrations of exposed IgG and sIgA, respectively, suggested that these act synergistically with mucin on the surface. In support of this hypothesis, quartz crystal microbalance with dissipation monitoring measurements revealed that a preadsorbed BSM layer stabilizes IgG through complexation on a polymeric model surface. Our findings link well to the complex in vivo situation and suggest that functional mucosal mimics can be created in situ for improved biomaterials performance.

Purification and characterization of an alpha-mannosidase from the tropical fruit babaco ( Vasconcellea x heilbornii Cv. babaco).

An alpha-mannosidase (EC 3.2.1.24) present in the lyophilized latex of babaco ( Vasconcellea heilbornii ) has been purified to apparent homogeneity by native PAGE. The purification involves a three-step procedure with successive anion exchange with Q Sepharose HP, lectin affinity chromatography using ConA Sepharose 4B, and gel filtration using Superdex 200 prep grade. The molecular mass was determined to be in the range of 260-280 kDa by Superdex 200 prep grade gel filtration, and isoelectric focusing showed a pI range between 5.85 and 6.55, suggesting different glycosylated isoforms. The optimal temperature for the alpha-mannosidase was determined to lie between 50 and 60 degrees C, and the optimal pH was 4.5 at 50 degrees C. The K(m) value for p-nitrophenyl alpha-mannopyranoside (pNPM) was found to be 1.25 mM and the V(max), 2.4 microkat mg(-1) at 50 degrees C and 1.94 microkat mg(-1) at 40 degrees C. The pure alpha-mannosidase was specific for mannose and did not display activity for any other tested synthetic substrates.

Ultra-sensitive immunochromatographic assay for quantitative determination of erythropoietin.

An ultra-sensitive quantitative EPO (erythropoietin) lateral flow immunochromatographic test with a detection limit of 1.2 fM (10(-15) M), 0.035 ng EPO/L, which is 50-100 times more sensitive than a corresponding enzyme based immunoassay, is presented. In comparison with commercial lateral flow tests for other analytes, like cardiac troponins that also require high sensitivity, the detection limit achieved in the presented test is about three orders of magnitude lower. The thin zone for capture and concentration of the analyte, the carbon black nano-strings used as label and the use of a conventional image scanner for the quantitative determination are the key components that enable the high sensitivity obtained. The convective flow in the lateral flow monolith creates short diffusion distances between immobilised antibody, analyte and labelled antibody thus enhancing the binding efficiency. This rapid and sensitive EPO test procedure can be used both to process hundreds of samples in 1 h and be utilized as a 15-minute dipstick test for single determinations. The technique is demonstrated by measuring EPO in urine. EPO, like many of the other urine proteins, is often found in the urine precipitates and the specimens are therefore treated with a urine precipitate dissolvation buffer before analysis. It is shown that EPO in urine from normal individuals occurs in low concentration in a wide range between 1.7 and 51 ng/L. The concentration is however subjected to a wide variation during the day due to the EPO production variation and the urine concentration by the kidneys. It is also shown that the presented lateral flow device can be used as a miniaturized affinity column to distinguish an analyte (EPO) from its analogue (darbepoetin), directly by comparing the affinity profiles obtained after interaction with the immobilised antibody. The method for measuring the amount of EPO present in urine, the possibility to rapidly check the amount of EPO after a pre-treatment concentration step, and the potential to identify affinity differences between EPO and its analogues should make the presented method a valuable tool in the fight against EPO doping.

Influence of nanoporesize on platelet adhesion and activation.

In this study we have evaluated the influence of biomaterial nano-topography on platelet adhesion and activation. Nano-porous alumina membranes with pore diameters of 20 and 200 nm were incubated with whole blood and platelet rich plasma. Platelet number, adhesion and activation were determined by using a coulter hematology analyzer, scanning electron microscopy, immunocytochemical staining in combination with light microscopy and by enzyme immunoassay. Special attention was paid to cell morphology, microparticle generation, P-selectin expression and beta-TG production. Very few platelets were found on the 200 nm alumina as compared to the 20 nm membrane. The platelets found on the 20 nm membrane showed signs of activation such as spread morphology and protruding filipodia as well as P-selectin expression. However no microparticles were detected on this surface. Despite the fact that very few platelets were found on the 200 nm alumina in contrast to the 20 nm membrane many microparticles were detected on this surface. Interestingly, all microparticles were found inside circular shaped areas of approximately 3 mum in diameter. Since this is the approximate size of a platelet we speculate that this is evidence of transient, non-adherent platelet contact with the surface, which has triggered platelet microparticle generation. To the authors knowledge, this is the first study that demonstrates how nanotexture can influence platelet microparticle generation. The study highlights the importance of understanding molecular and cellular events on nano-level when designing new biomaterials.

Mucin coatings suppress neutrophil adhesion to a polymeric model biomaterial.

Following our recent study on the fractionation, characterization, and model adsorption of mucins derived from bovine salivary glands (BSM), porcine stomach scrapings (PGM), and human whole saliva (MG1), we here present a microscopic evaluation of the interactions between mucin-coated substrates and human neutrophils. Our results show that surface-coating with BSM, PGM, and MG1 can be effectively used to suppress the adhesion of neutrophils to a polymeric model biomaterial (Thermanox). Neutrophil morphologies found on Thermanox substrates coated with mucins resemble those observed for nonactivated neutrophils found in circulation. Notably, low neutrophil adhesion can be obtained at a significantly lower coating concentration (0.125 mg/mL) for the compositionally complex MG1 mucin than for the relatively pure BSM and PGM mucins (1 mg/mL). Furthermore, since coating at a low BSM and PGM concentration (0.25 mg/mL) results in higher cell counts and more spread cells than in the high-concentration case, we suggest that dense mucin surface packing is critical for good coating performance. In conclusion, the present study demonstrates how mucins from three different sources, of different compositional and structural status, efficiently can be used to suppress neutrophil adhesion and activation. This finding makes them potent candidates for use as biomaterial coatings.