The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in older adults with chronic illness - a mixed methods study.

BACKGROUND: Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness. METHODS: The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission. RESULTS: All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions. CONCLUSIONS: While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge. TRIAL REGISTRATION: Clinical Trials. giv, NCT02823795, 01/09/2016.

Medical secretaries' fears and opportunities in an increasingly digitalised workplace environment.

PURPOSE: The purpose of this mixed-methods study was to explore how medical secretaries experience digital transformation in a Swedish healthcare organisation, with a focus on workplace climate and health. DESIGN/METHODOLOGY/APPROACH: Data were collected using a sequential exploratory mixed-methods design based on grounded theory, with qualitative data collection (a Quality Café and individual interviews) followed by quantitative data collection (a questionnaire). FINDINGS: Four categories with seven underlying factors were identified, emphasising the crucial need for effective organisation of digital transformation. This is vital due to the increased knowledge and skills in utilising technology. The evolving roles and responsibilities of medical secretaries in dynamic healthcare settings should be clearly defined and acknowledged, highlighting the importance of professionality. Ensuring proper training for medical secretaries and other occupations in emerging techniques is crucial, emphasising equal value and knowledge across each role. Associations were found between some factors and the health of medical secretaries. RESEARCH LIMITATIONS/IMPLICATIONS: This study adds to the knowledge on digital transformation in healthcare by examining an important occupation. Most data were collected online, which may be a limitation of this study. PRACTICAL IMPLICATIONS: Several aspects of the medical secretaries' experiences were identified. Knowledge of these is valuable for healthcare managers to make digital transformation more effective while avoiding excessive strain on medical secretaries. ORIGINALITY/VALUE: Medical secretaries are expected to contribute to the digitalisation of healthcare. However, minimal research has been conducted on the role of medical secretaries in workplace digitalisation, focusing on workplace roles and its dynamics.

Challenges with Medication Management and the National Medication List in Sweden: An Interview Study from a Human, Organizational, and Technology Perspective.

Sweden is in the process of implementing the National Medication List (NLL). The aim of this study was to explore the challenges with the medication management process, as well as expectation for NLL, from a human, organizational, and technology perspective. This study included interviews with prescribers, nurses, pharmacists, patients, and their relatives and was conducted during March to June 2020, before the implementation of NLL. Challenges were (1) feeling lost with several different medication lists, (2) spending time searching for information, (3) being frustrated at parallel information systems, (4) patients being the carriers of information, and (5) the feeling of being responsible in an indistinct process. The expectations for NLL in Sweden were high, but there were several fears.

Health Care Professionals' Experiences in Telerehabilitation: Qualitative Content Analysis.

BACKGROUND: The use of digital communication in Swedish health care has increased in an effort to make health care more accessible. At the organizational level, trust in digitalization has stabilized, but a certain degree of skepticism regarding technology appears to exist among health care employees. OBJECTIVE: This study aimed to explore health care professionals' (HCPs) experiences of digital communication with patients and colleagues in a habilitation context. METHODS: Qualitative content analysis was used to analyze data derived from individual interviews. RESULTS: The results revealed that there were mixed feelings regarding the digital format used at the habilitation center. Although some skepticism remained regarding the digital format, there seemed to be a parallel understanding of the motives and benefits of digitalization. Hence, positive aspects, such as increased health care accessibility, were identified. However, emphasis was placed on the considerations required to make digital consultations appropriate for each patient. CONCLUSIONS: Managing a workday influenced by the balance between digital and physical demands forces HCPs to adjust to the digital format and new ways of working. This requires HCPs to consider whether digital means are appropriate for communication in individual patient-specific cases.

Reduced glucose tolerance and insulin sensitivity after prolonged exercise in endurance athletes.

AIM: The purpose of this study was to 1. investigate if glucose tolerance is affected after one acute bout of different types of exercise; 2. assess if potential differences between two exercise paradigms are related to changes in mitochondrial function; and 3. determine if endurance athletes differ from nonendurance-trained controls in their metabolic responses to the exercise paradigms. METHODS: Nine endurance athletes (END) and eight healthy nonendurance-trained controls (CON) were studied. Oral glucose tolerance tests (OGTT) and mitochondrial function were assessed on three occasions: in the morning, 14 h after an overnight fast without prior exercise (RE), as well as after 3 h of prolonged continuous exercise at 65% of VO2 max (PE) or 5 × 4 min at ~95% of VO2 max (HIIT) on a cycle ergometer. RESULTS: Glucose tolerance was markedly reduced in END after PE compared with RE. END also exhibited elevated fasting serum FFA and ketones levels, reduced insulin sensitivity and glucose oxidation, and increased fat oxidation during the OGTT. CON showed insignificant changes in glucose tolerance and the aforementioned measurements compared with RE. HIIT did not alter glucose tolerance in either group. Neither PE nor HIIT affected mitochondrial function in either group. END also exhibited increased activity of 3-hydroxyacyl-CoA dehydrogenase activity in muscle extracts vs. CON. CONCLUSION: Prolonged exercise reduces glucose tolerance and increases insulin resistance in endurance athletes the following day. These findings are associated with an increased lipid load, a high capacity to oxidize lipids, and increased fat oxidation.

Communication about medication management during patient-physician consultations in primary care: a participant observation study.

OBJECTIVE: To explore communication about medication management during annual consultations in primary care. DESIGN: passive participant observations of primary care consultations. SETTING: Two primary care centres in southern Sweden. PARTICIPANTS: Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis. RESULTS: Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further. CONCLUSION: Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.

Using a Proximity-Detection Technology to Nudge for Physical Distancing in a Swedish Workplace During the COVID-19 Pandemic: Retrospective Case Study.

BACKGROUND: The recent COVID-19 pandemic has contributed to the emergence of several technologies for infectious disease management. Although much focus has been placed on contact-tracing apps, another promising new tactic is proximity tracing, which focuses on health-related behavior and can be used for primary prevention. Underpinned by theories on behavioral design, a proximity-detection system can be devised that provides a user with immediate nudges to maintain physical distance from others. However, the practical feasibility of proximity detection during an infectious disease outbreak has not been sufficiently investigated. OBJECTIVE: We aimed to evaluate the feasibility of using a wearable device to nudge for distance and to gather important insights about how functionality and interaction are experienced by users. The results of this study can guide future research and design efforts in this emerging technology. METHODS: In this retrospective case study, a wearable proximity-detection technology was used in a workplace for 6 weeks during the production of a music competition. The purpose of the technology was to nudge users to maintain their physical distance using auditory feedback. We used a mixed methods sequential approach, including interviews (n=8) and a survey (n=30), to compile the experiences of using wearable technology in a real-life setting. RESULTS: We generated themes from qualitative analysis based on data from interviews and open-text survey responses. The quantitative data were subsequently integrated into these themes: feasibility (implementation and acceptance-establishing a shared problem; distance tags in context-strategy, environment, and activities; understanding and learning; and accomplishing the purpose) and design aspects (a purposefully annoying device; timing, tone, and proximity; and additional functions). CONCLUSIONS: This empirical study reports on the feasibility of using wearable technology based on proximity detection to nudge individuals to maintain physical distance in the workplace. The technology supports attention to distance, but the usability of this approach is dependent on the context and situation. In certain situations, the audio signal is frustrating, but most users agree that it needs to be annoying to ensure sufficient behavioral adaption. We proposed a dual nudge that involves vibration followed by sound. There are indications that the technology also facilitates learning how to maintain a greater distance from others, and that this behavior can persist beyond the context of technology use. This study demonstrates that the key value of this technology is that it places the user in control and enables immediate action when the distance to others is not maintained. This study provides insights into the emerging field of personal and wearable technologies used for primary prevention during infectious disease outbreaks. Future research is needed to evaluate the preventive effect on transmission and investigate behavioral changes in detail and in relation to different forms of feedback.

A Simple Model for Diagnosis of Maladaptations to Exercise Training.

BACKGROUND: The concept of overreaching and super compensation is widely in use by athletes and coaches seeking to maximize performance and adaptations to exercise training. The physiological aspects of acute fatigue, overreaching and non-functional overreaching are, however, not well understood, and well-defined negative physiological outcomes are missing. Instead, the concept relies heavily on performance outcomes for differentiating between the states. Recent advancements in the field of integrated exercise physiology have associated maladaptations in muscular oxidative function to high loads of exercise training. METHOD: Eleven female and male subjects that exercised regularly but did not engage in high-intensity interval training (HIIT) were recruited to a 4-week long training intervention where the responses to different training loads were studied. Highly monitored HIIT sessions were performed on a cycle ergometer in a progressive fashion with the intent to accomplish a training overload. Throughout the intervention, physiological and psychological responses to HIIT were assessed, and the results were used to construct a diagnostic model that could indicate maladaptations during excessive training loads. RESULTS: We here use mitochondrial function as an early marker of excessive training loads and show the dynamic responses of several physiological and psychological measurements during different training loads. During HIIT, a loss of mitochondrial function was associated with reduced glycolytic, glucoregulatory and heart rate responses and increased ratings of perceived exertion in relation to several physiological measurements. The profile of mood states was highly affected after excessive training loads, whereas performance staled rather than decreased. By implementing five of the most affected and relevant measured parameters in a diagnostic model, we could successfully, and in all the subjects, identify the training loads that lead to maladaptations. CONCLUSIONS: As mitochondrial parameters cannot be assessed without donating a muscle biopsy, this test can be used by coaches and exercise physiologists to monitor adaptation to exercise training for improving performance and optimizing the health benefits of exercise. Clinical trial registry number NCT04753021 . Retrospectively registered 2021-02-12.

Effects of Plyometric Training on Soft and Hard Surfaces for Improving Running Economy.

The present study investigated the effects of plyometric jump training on hard and soft surfaces on running economy (RE), maximal oxygen uptake (VO2max), running performance and the rate of force development in orienteers. Nineteen orienteers (11 women and 8 men, body mass 61.1 ± 7.3 kg, age 21 ± 5.8 yrs) were randomly stratified based on sex, age, VO2max and RE to plyometric jumping training (8 sessions over 4 weeks) on either a hard or a soft surface. RE, VO2max and running performance were assessed on a treadmill and outdoor on- and off-trail loops. Moreover, ground reaction forces and force development were assessed during a one leg drop-jump test. The training intervention led to an overall 2-7% improvement in treadmill and off-trail RE, independent of the jumping surface and running velocity assessed. These improvements were not explained by force development during drop jump tests, which remained unchanged following the intervention. The changes in time-trial performance were associated with changes in RE. Plyometric training improved RE with no difference between the hard or the soft training surface and improved RE was also independent of the running speed assessed. Furthermore, improved running performance was associated with changes in RE after the intervention.

The Drug Factory: Industrializing How New Drugs Are Found.

In this perspective, the authors paint a vision for industrializing drug discovery with an "atoms and bits" approach. This approach leverages advancements in machine learning, automation, and biological tools to create a platform for drug discovery that de-specializes the output of insights and generates feedback loops to iterate on each success and failure. Recursion Pharmaceuticals, where the authors work, is provided as an example of how one company is attempting to achieve this vision.

Excessive exercise training causes mitochondrial functional impairment and decreases glucose tolerance in healthy volunteers.

Exercise training positively affects metabolic health through increased mitochondrial oxidative capacity and improved glucose regulation and is the first line of treatment in several metabolic diseases. However, the upper limit of the amount of exercise associated with beneficial therapeutic effects has not been clearly identified. Here, we used a training model with a progressively increasing exercise load during an intervention over 4 weeks. We closely followed changes in glucose tolerance, mitochondrial function and dynamics, physical exercise capacity, and whole-body metabolism. Following the week with the highest exercise load, we found a striking reduction in intrinsic mitochondrial function that coincided with a disturbance in glucose tolerance and insulin secretion. We also assessed continuous blood glucose profiles in world-class endurance athletes and found that they had impaired glucose control compared with a matched control group.

Older persons' experience of eHealth services in home health care: A meta-ethnography eHealth services in home health care.

This study aimed to describe older persons' experiences of eHealth services in home health care. A meta-ethnographic approach was applied, and a systematic literature search was conducted in three databases. In total, 11 articles were included and analysed, which resulted in two themes and six sub-themes. The results show that for older persons to use the eHealth services, they must provide some additional value compared to current contacts with healthcare professionals. Those with regular healthcare contact do not experience the eHealth service as adding anything to the care they already receive. The introduction of eHealth services involves learning how to use the new technology, and some older persons experience the technology as motivating and inspiring. The eHealth service makes some feel safer while some do not trust the technology. In order to make the best use of eHealth services, it is important that the services are adjusted not only to each person's needs but also to their personal capabilities and resources, while the older person must feel valued as an active partner in the care process. Thus, when using eHealth services, the older person's perspective needs to be given priority and decisions should not only be based on organizational considerations.

Patients' experiences of using an e-Health tool for self-management support after prostate cancer surgery: a deductive interview study explained through the FITT framework.

OBJECTIVE: To evaluate patients' experiences of using a web-based application, especially its usability as support for self-care activities after prostate cancer surgery. DESIGN: A deductive content analysis was used, stemming from the Fit between Individuals, Task and Technology (FITT) framework. SETTING: One surgical department in south of Sweden between October 2015 and April 2016 and between September 2017 and July 2018. PARTICIPANTS: Fifteen men who had undergone radical prostatectomy for prostate cancer. RESULTS: By organising data in accordance with the FITT model, three main categories with ten subcategories were identified. Patients gave feedback on functions that suited them and their needs, as well as potential adjustments and improvements. Patients experienced that ePATH gave them easy access to reliable information regarding their rehabilitation. Directed information about ePATH at enrolment was seen as important. ePATH was perceived to have a logical structure that was easy to follow. However, when the structure was unclear, patients became less motivated to use a function. CONCLUSIONS: Patients experienced ePATH as satisfactorily user-friendly and useful as a complementary self-management support after prostate cancer surgery, especially when the information and tasks were tailored to their preferences and the system design features supported individual autonomy.

Enhanced Patient Activation in Cancer Care Transitions: Protocol for a Randomized Controlled Trial of a Tailored Electronic Health Intervention for Men With Prostate Cancer.

BACKGROUND: Prostate cancer has increased in incidence worldwide and is the leading cause of cancer death in 24 countries. The most common treatment is radical prostatectomy. However, surgery is associated with postoperative complications such as urinary incontinence and sexual dysfunction, causing decreased quality of life. If survivors are encouraged to be more active in self-care management, the symptom burden may decrease and quality of life may improve. An electronic health (eHealth) intervention based on motivational behavioral theory has been developed for this purpose. OBJECTIVE: This study aimed to compare the effectiveness of standard care in combination with a tailored eHealth and mobile health self-management support system, electronic Patient Activation in Treatment at Home (ePATH), with standard care of adverse effects of prostate cancer treatment (urinary incontinence and sexual functioning) in men undergoing radical prostatectomy. The secondary aim was to test the effect on patient activaftion, motivation, overall well-being, and health literacy over time in and between groups. METHODS: A pragmatic multicenter, block-randomized controlled trial with 2 study arms, standard care (control) and eHealth-assisted standard care (intervention), for patients undergoing radical prostatectomy. For 80% power, a sample of 242 men will need to be recruited. RESULTS: Recruitment started in January 2018 and is expected to be completed by August 2019. Data collection will be completed in August 2020. The first cross-sectional results from this trial are anticipated to be published in January 2020. CONCLUSIONS: With the increasing number of prostate cancer survivors, attention should be paid to rehabilitation, psychosocial care, and support for endurance of self-care to reduce suffering from adverse treatment effects, poor quality of life, and depression because of postoperative complications. This project may increase knowledge of how patients can be supported to feel involved in their care and returning to as normal a life as possible. The anticipated effects of ePATH could improve health outcomes for individuals and facilitate follow-up for health care professionals. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: 18055968; http://www.isrctn.com/ISRCTN18055968 (Archived by WebCite at http://www.isrctn.com/ISRCTN18055968). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11625.

Scanning electron microscopy as a tool for evaluating morphology of amyloid structures formed on surface plasmon resonance chips.

We demonstrate the use of Scanning Electron microscopy (SEM) in combination with Surface Plasmon Resonance (SPR) to probe and verify the formation of amyloid and its morphology on an SPR chip. SPR is a technique that measures changes in the immobilized weight on the chip surface and is frequently used to probe the formation and biophysical properties of amyloid structures. In this context it is of interest to also monitor the morphology of the formed structures. The SPR chip surface is made of a layer of gold, which represent a suitable material for direct analysis of the surface using SEM. The standard SPR chip used here (CM5-chip, GE Healthcare, Uppsala, Sweden) can easily be disassembled and directly analyzed by SEM. In order to verify the formation of amyloid fibrils in our experimental conditions we analyzed also in-solution produced structures by using Transmission Electron Microscopy (TEM). For further details and experimental findings, please refer to the article published in Journal of Molecular Biology, (Brännström K. et al., 2018) [1].

Decision-makers and mediators in a home healthcare digitisation process: nurses' experiences of implementation and use of a decision support system.

BACKGROUND: This study focuses on a decision support system (DSS) for home healthcare and the implementation of it. AIM: To describe home healthcare nurses' experiences of the implementation and use of a new DSS, with a focus on how it influences decision making in everyday work practice. DESIGN: A qualitative research design. METHODS: Data was collected through three focus group interviews with six home healthcare nurses.The data analysis was drawn from Burnard's method for content analysis. RESULTS: The DSS was experienced as bringing support to decisions, but sometimes incompatible with home healthcare nurses' work practice. Professional understanding and the DSS were sometimes experienced as parallel support systems not assisting work across healthcare organisations. CONCLUSION: When a DSS is used to transform work of healthcare organisations several aspects should be highlighted. If the organisation does not consider these aspects, nurses may adopt a role as mediator in the implementation process.

Transthyretin Interferes with Aß Amyloid Formation by Redirecting Oligomeric Nuclei into Non-Amyloid Aggregates.

The pathological Aß aggregates associated with Alzheimer's disease follow a nucleation-dependent path of formation. A nucleus represents an oligomeric assembly of Aß peptides that acts as a template for subsequent incorporation of monomers to form a fibrillar structure. Nuclei can form de novo or via surface-catalyzed secondary nucleation, and the combined rates of elongation and nucleation control the overall rate of fibril formation. Transthyretin (TTR) obstructs Aß fibril formation in favor of alternative non-fibrillar assemblies, but the mechanism behind this activity is not fully understood. This study shows that TTR does not significantly disturb fibril elongation; rather, it effectively interferes with the formation of oligomeric nuclei. We demonstrate that this interference can be modulated by altering the relative contribution of elongation and nucleation, and we show how TTR's effects can range from being essentially ineffective to almost complete inhibition of fibril formation without changing the concentration of TTR or monomeric Aß.

The Properties of Amyloid-ß Fibrils Are Determined by their Path of Formation.

Fibril formation of the amyloid-ß peptide (Aß) follows a nucleation-dependent polymerization process and is associated with Alzheimer's disease. Several different lengths of Aß are observed in vivo, but Aß1-40 and Aß1-42 are the dominant forms. The fibril architectures of Aß1-40 and Aß1-42 differ and Aß1-42 assemblies are generally considered more pathogenic. We show here that monomeric Aß1-42 can be cross-templated and incorporated into the ends of Aß1-40 fibrils, while incorporation of Aß1-40 monomers into Aß1-42 fibrils is very poor. We also show that via cross-templating incorporated Aß monomers acquire the properties of the parental fibrils. The suppressed ability of Aß1-40 to incorporate into the ends of Aß1-42 fibrils and the capacity of Aß1-42 monomers to adopt the properties of Aß1-40 fibrils may thus represent two mechanisms reducing the total load of fibrils having the intrinsic, and possibly pathogenic, features of Aß1-42 fibrils in vivo. We also show that the transfer of fibrillar properties is restricted to fibril-end templating and does not apply to cross-nucleation via the recently described path of surface-catalyzed secondary nucleation, which instead generates similar structures to those acquired via de novo primary nucleation in the absence of catalyzing seeds. Taken together these results uncover an intrinsic barrier that prevents Aß1-40 from adopting the fibrillar properties of Aß1-42 and exposes that the transfer of properties between amyloid-ß fibrils are determined by their path of formation.

Developing an eHealth Tool to Support Patient Empowerment at Home.

In previous research we have learned that patients with chronic or complex diseases often experience difficulties when transitioning from hospital care to self-care in their home. We address these difficulties by developing an eHealth tool for patients - ePATH (electronic Patient Activation in Treatment at Home) - intended to empower each patient to manage their individual situation. We have employed a user-centered design process involving both patients and healthcare personnel to specify the content and functionality of ePATH. The system is deployed as a web application with secure login for patients. In this article, we describe the main content and functionality of the system that makes it possible for a patient to manage symptoms development in relation to treatment progression Interactive functionality, e.g., reminders and social support, is included to make the ePATH a useful and informative bridge between patients, next-of-kin and different caregivers. One lesson learned is that it is necessary to incorporate motivational components in the development of an eHealth tool to successfully overcome the "intention-behavior" gap. The self-determination theory of motivation can be used to ensure that important aspects are not missed.

Nurses' Use and Perception of an Information and Communication Technology System for Improving Coordination During Hospital Discharges: A Survey in Swedish Primary Healthcare.

To facilitate communications between care levels and improve coordination during hospital discharges, there is great potential in using information and communication technology systems, because they can significantly help to deter unnecessary readmissions. However, there is still a lack of knowledge about how often nurses use information and communication technology and the indicators related to its use. The aims of this study were to describe the indicators related to nurses' use of an information and communication technology system for collaboration between care levels and to estimate whether the level of use can be related to nurses' perceptions of the information and communication technology system's contribution to improve coordination during hospital discharges. A quantitative survey of 37 nurses from 11 primary healthcare centers was performed in a county in southern Sweden. The data were analyzed using descriptive and comparative analyses. The results showed that perceptions concerning the information and communication technology system's usability and time consumption differed between nurses who used the system and those who did not. Simultaneously, the nurses were rather unaware of the ability of the information and communication technology system to improve coordination during patient discharges.