On the edge of decision-making in trauma care: A focus group study on radiographers' experiences of interprofessional collaboration.

INTRODUCTION: The temporary trauma teams in trauma alerts consist of a diverse group of unique professionals requiring interprofessional collaboration and coordination to achieve efficient, high-quality care. The uncertain situation and complex care environment impose high demands on team dynamics such as individual attitudes and team behaviours. Within interprofessional teams, interaction and coordination reflect the collective success of collaboration and the achievement of goals. Interactions with radiographers have increased in trauma teams given computed tomography's prominent role in providing crucial knowledge for decision-making in trauma care. This study aimed to explore radiographers' experiences of interprofessional collaboration during trauma alerts. METHOD: The study was designed with focus group methodology, including 17 radiographers participating in five focus groups, analysed with an inductive focus group analysis. RESULTS: An overarching theme, "On the edge of decision-making", emerged along with three sub-themes: "Feeling included requires acknowledgement", "Exclusion precludes shared knowledge", and "Experience and mutual awareness facilitate team interaction". CONCLUSIONS: Interprofessional collaboration from the radiographer's perspective within trauma teams requires a sense of inclusion and the ability to interact with the team. Exclusion from vital decision-making obstructs radiographers' comprehension of situations and thereby the interdependence in interprofessional collaboration. IMPLICATIONS FOR PRACTICE: Common platforms are needed for knowledge sharing and team practices, including radiographers' areas of responsibility and relational coordination to foster interprofessional relationships. Through these means interdependence through awareness and shared knowledge can be facilitated on trauma teams.

Health economic evaluation of a randomized controlled trial (EMBLA study), an internet-based treatment for provoked vulvodynia.

Internet-based treatment (IBT) for provoked vulvodynia (PVD) may reduce pain during intercourse and increases pain acceptance. However, a there is still a knowledge gap regarding the cost-effectiveness of IBT for PVD. The aim of this study was to perform a health economic evaluation of guided internet-based intervention for PVD as an addition to standard treatment. The sample consisted of 99 women with a PVD diagnosis. Healthcare related costs, health-related quality of life, and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were analyzed. After the IBT, the intervention group had fewer visits to a midwife than the control group (p = 0.03), but no between-group differences were found for visits to other professionals, treatment length, health-related quality of life, QALYs, and costs for treatment. It was estimated a cost of 260.77 € for a clinical meaningful change in pain acceptance. Internet-based treatment as add-on to clinical treatment may lower number of visits to a healthcare.

Evaluating reflective practice groups in a mental health context: Swedish translation and psychometric evaluation of the clinical supervision evaluation questionnaire.

BACKGROUND: Implementation of reflective practice groups in psychiatric and mental health contexts might improve the quality of care through promoting self-awareness, clinical insight, and facilitating stress management and team building. There is a need for valid and reliable instruments to test the outcomes of reflective practice groups in the mental health context. This study aimed to test the validity and reliability of the Swedish version of the Clinical Supervision Evaluation Questionnaire. METHODS: The instrument was translated from English to Swedish using a translation and back-translation procedure. Data for the calculation of content validity was collected from an expert group. Data for the reliability analysis was collected from rehabilitation assistants and ward managers participating in reflective practice groups (n = 20). Content validity was measured by computing a content validity index. Construct validity was assessed by calculating the corrected item-total correlation statistics. Reliability was evaluated by analysing the Cronbach's alpha coefficient, the intraclass correlation coefficient and inter-item correlations. RESULTS: The content validity index for the scale as a whole was 0.94. Item-total correlations ranged between 0.23 and 0.81, and deletion of an item did not notably improve Cronbach's alpha. Cronbach's alpha for the scale was 0.89. The intraclass correlation coefficient for single measures was 0.35. The mean inter-item correlation was .37. CONCLUSION: The Swedish version of the Supervision Evaluation Questionnaire has a degree of reliability and validity that is comparable to the original version in English, indicating that it can be used as an assessment of reflective practice groups in the mental health context.

Theoretical and hands-on guidance from dental hygienists promotes good oral health in elderly people living in nursing homes, a pilot study.

OBJECTIVES: Oral health in nursing homes for elderly is often unsatisfactory, and oral health education to nursing staff has not shown sufficient results why there is need for novel approaches. The aim of the study was to trial a new oral healthcare educational programme and to evaluate the effects on residents' oral health. In addition, attitudes among the nursing staff in the intervention nursing home were explored. METHODS: In a controlled clinical trial, two comparable nursing homes were randomly assigned for intervention or control. Interventions included weekly theoretical and hands-on guidance from dental hygienists on oral hygiene procedures and discussions on oral care routines. The residents' oral health, measured by the Revised Oral Assessment Guide (ROAG), dental plaque and gingival bleeding were evaluated at baseline and after 3 months. Attitudes among the staff to oral health care were measured at the intervention nursing home. RESULTS: Revised Oral Assessment Guide gums and lips scores showed a tendency to decrease in the intervention group, but remained high in the control group. Plaque levels improved significantly after intervention, and a trend towards less gingival bleeding was observed. The intervention nursing staff seemed to be more aware of their own limitations concerning oral health care after intervention and valued more frequent contact with dental services to a greater extent. CONCLUSIONS: The oral healthcare situation for elderly people today is so complex that theoretical education at the group level regarding different aspects of oral health is not sufficient. Individual hands-on guidance by dental hygienists on a regular basis in everyday care may be a new approach.

Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis.

PURPOSE: Veno-arterial extracorporeal life support (ECLS) is increasingly used in patients during cardiac arrest and cardiogenic shock, to support both cardiac and pulmonary function. We performed a systematic review and meta-analysis of cohort studies comparing mortality in patients treated with and without ECLS support in the setting of refractory cardiac arrest and cardiogenic shock complicating acute myocardial infarction. METHODS: We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the publisher subset of PubMed updated to December 2015. Thirteen studies were included of which nine included cardiac arrest patients (n = 3098) and four included patients with cardiogenic shock after acute myocardial infarction (n = 235). Data were pooled by a Mantel-Haenzel random effects model and heterogeneity was examined by the I 2 statistic. RESULTS: In cardiac arrest, the use of ECLS was associated with an absolute increase of 30 days survival of 13 % compared with patients in which ECLS was not used [95 % CI 6-20 %; p < 0.001; number needed to treat (NNT) 7.7] and a higher rate of favourable neurological outcome at 30 days (absolute risk difference 14 %; 95 % CI 7-20 %; p < 0.0001; NNT 7.1). Propensity matched analysis, including 5 studies and 438 patients (219 in both groups), showed similar results. In cardiogenic shock, ECLS showed a 33 % higher 30-day survival compared with IABP (95 % CI, 14-52 %; p < 0.001; NNT 13) but no difference when compared with TandemHeart/Impella (-3 %; 95 % CI -21 to 14 %; p = 0.70; NNH 33). CONCLUSIONS: In cardiac arrest, the use of ECLS was associated with an increased survival rate as well as an increase in favourable neurological outcome. In the setting of cardiogenic shock there was an increased survival with ECLS compared with IABP.

Northern fowl mite (Ornithonyssus sylviarum) in Sweden.

Haematophagous mites were collected from the vent region and plumage of chickens in six hobby flocks of ornamental breeds in Sweden, one of which included turkeys. Soiled vent skin and feathers, dermatitis, hyperkeratosis, skin necroses and ulcers were observed in 12 necropsied birds from two of the flocks. The mites were identified as the northern fowl mite Ornithonyssus sylviarum (Mesostigmata: Macronyssidae). This was supported by sequence analysis of a 642-bp region in the mitochondrial cytochrome oxidase subunit 1 (COI) gene (COI) in mites collected from five flocks, which showed 97-99% sequence similarity to O. sylviarum by blast analysis. Pairwise sequence comparisons revealed nucleotide variations in the range of 0-2.8%, whereas amino acid sequences were highly conserved. This paper represents one of very few records of O. sylviarum in European poultry, and is the first to report COI sequence data for O. sylviarum from poultry in Europe.

Mechanical circulatory support with the Impella 5.0 device for postcardiotomy cardiogenic shock: a three-center experience.

AIM: Postcardiotomy cardiogenic shock (PCCS) is associated with high mortality rates, despite full conventional treatment. Although the results of treatment with surgically implantable ventricular assist devices have been encouraging, the invasiveness of this treatment limits its applicability. Several less invasive devices have been developed, including the Impella system. The objective of this study was to describe our three-center experience with the Impella 5.0 device in the setting of PCCS. METHODS: From January 2004 through December 2010, a total of 46 patients were diagnosed with treatment-refractory PCCS and treated with the Impella 5.0 percutaneous left ventricular assist device at three european heart centers. Baseline and follow-up characteristics were collected retrospectively and entered into a dedicated database. RESULTS: Within the study cohort of 46 patients, mean logistic and additive EuroSCORES were 24 ± 19 and 10 ± 4. The majority of patients underwent coronary artery bypass grafting (48%) or combined surgery (33%). Half of all patients had been treated with an intra-aortic balloon pump before 5.0-implantation, 1 patient had been treated with an Impella 2.5 device. All patients were on mechanical ventilation and intravenous inotropes. The Kaplan-Meier estimate of overall 30-day survival was 39.5%. CONCLUSION: Thirty-day survival rates for patients with PCCS, refractory to aggressive conventional treatment and treated with the Impella 5.0 device, are comparable to those reported in studies evaluating surgically implantable VADs, whereas the Impella system is much less invasive. Therefore, mechanical circulatory support with the Impella 5.0 device is a suitable treatment modality for patients with severe PCCS.

Real-time PCR detection for quantification of infection levels with Ostertagia ostertagi and Cooperia oncophora in cattle faeces.

A quantitative real-time polymerase chain reaction (qPCR) based on hydrolysis (TaqMan) probes is described for robust and sensitive detection of the infection levels with eggs and third stage larvae (L3) of Cooperia oncophora and Ostertagia ostertagi isolated from cattle faeces. The current microscopic method for identification of strongyle nematodes in cattle faeces is labour-intensive where reliable species determination also requires trained expertise, which is increasingly lacking. The goal of this study was to develop a sustainable non-labour intensive diagnostic qPCR assay to detect and determine the levels of infection with the two most common gastro-intestinal nematodes (GIN) in cattle faeces targeting the second internal transcribed spacer of nuclear ribosomal DNA (ITS2) region (rDNA). According to our results, this procedure allows to reliably detect the relative proportions of eggs and L3 for each of the two species. This assay produced consistent results when mixtures with known numbers of L3 of both species were tested, although it was also demonstrated that the calculated copy numbers of ITS2 between single L3 sometimes varied very much. In addition, a positive correlation (r(2)=0.23) between the proportion of eggs and L3 in different paired samples collect in the field was observed for both species. Thus, for the first time a qPCR assay is reported, which can discriminate between the two most important cattle nematode parasites in temperate regions. This is of major importance to the livestock sector as it can be used with great precision to demonstrate strategic treatment efficacy that is important for the detection of anthelmintic resistance (AR).

Sequencing of the ß-tubulin genes in the ascarid nematodes Parascaris equorum and Ascaridia galli.

Benzimidazoles (BZ) are used to control infections of the equine roundworm Parascaris equorum and the poultry roundworm Ascaridia galli. There are still no reports of anthelmintic resistance (AR) to BZ in these two nematodes, although AR to BZ is widespread in several other veterinary parasites. Several single nucleotide polymorphisms (SNP) in the ß-tubulin genes have been associated with BZ-resistance. In the present study we have sequenced ß-tubulin genes: isotype 1 and isotype 2 of P. equorum and isotype 1 of A. galli. Phylogenetic analysis of all currently known isotypes showed that the Nematoda has more diversity among the ß-tubulin genes than the Vertebrata. In addition, this diversity is arranged in a more complex pattern of isotypes. Phylogenetically, the A. galli sequence and one of the P. equorum sequences clustered with the known Ascaridoidea isotype 1 sequences, while the other P. equorum sequence did not cluster with any other ß-tubulin sequences. We therefore conclude that this is a previously unreported isotype 2. The ß-tubulin gene sequences were used to develop a PCR for genotyping SNP in codons 167, 198 and 200. No SNP was observed despite sequencing 95 and 100 individual adult worms of P. equorum and A. galli, respectively. Given the diversity of isotype patterns among nematodes, it is likely that associations of genetic data with BZ-resistance cannot be generalised from one taxonomic group to another.

Population genetics of Parascaris equorum based on DNA fingerprinting.

The large roundworm of horses, Parascaris equorum is considered ubiquitous in breeding operations, and is regarded as a most important helminth pathogen of foals. Over the past decade, this parasite has been reported increasingly resistant to anthelmintic drugs worldwide. This paper reports analysis of the population genetic structure of P. equorum. Adult parasites (n=194) collected from Sweden, Norway, Iceland, Germany, Brazil and the USA were investigated by amplified restriction fragment length polymorphism (AFLP) analysis. The genetic variation was low (Hj=0.12-0.4), for the global population of worms. This was accompanied by a weak degree of population structure (Fst=0.2), low gene flow (Nm=1.0) and low mutation rate (4 Nµ=0.07). Thus, the low genetic diversity is probably a result of a low mutation rate in DNA, although the gene flow (due to global movement of horses) is large enough to allow the spread of novel mutations. Surprisingly, isolates from Icelandic horses were not found to be different from other isolates, in spite of the fact that these have been isolated for thousands of years. The study indicates that the global P. equorum population is essentially homogenous, and continents do not appear to be strong barriers for the population structure of this species. Consequently, the potential spread of rare anthelmintic resistance genes may be rapid in a homogenous population.

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality. METHODS: From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n = 59) and 'IABP post PCI' (n = 140). Outcomes were assessed by propensity stratification and multivariate logistic regression. RESULTS: All-cause 30-day mortality for the IABP versus the no IABP group was 47 % vs. 28 %, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64 % vs. 40 %, resulting in an OR of 1.56 (95 % CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality. CONCLUSION: In our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the 'no IABP' group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.

Students' learning as the focus for shared involvement between universities and clinical practice: a didactic model for postgraduate degree projects.

In an academic programme, completion of a postgraduate degree project could be a significant means of promoting student learning in evidence- and experience-based practice. In specialist nursing education, which through the European Bologna process would be raised to the master's level, there is no tradition of including a postgraduate degree project. The aim was to develop a didactic model for specialist nursing students' postgraduate degree projects within the second cycle of higher education (master's level) and with a specific focus on nurturing shared involvement between universities and healthcare settings. This study embodies a participatory action research and theory-generating design founded on empirically practical try-outs. The 3-year project included five Swedish universities and related healthcare settings. A series of activities was performed and a number of data sources secured. Constant comparative analysis was applied. A didactic model is proposed for postgraduate degree projects in specialist nursing education aimed at nurturing shared involvement between universities and healthcare settings. The focus of the model is student learning in order to prepare the students for participation as specialist nurses in clinical knowledge development. The model is developed for the specialist nursing education, but it is general and could be applicable to various education programmes.

Multiple antibody reactivities to citrullinated antigens in sera from patients with rheumatoid arthritis: association with HLA-DRB1 alleles.

BACKGROUND: Autoantibodies to cyclic citrullinated peptides (anti-CCP) are present in most patients with rheumatoid arthritis (RA), and associate with HLA-DRB1 shared epitope (SE) alleles. OBJECTIVE: To investigate reactivities of anti-CCP to various citrullinated proteins/peptides, which represent potential autoantigens in RA, and to examine the relationship between such antibodies, and their association with genetic variants within HLA-DRB1 SE alleles. METHODS: Serum samples from 291 patients with established RA and 100 sex- and age-matched healthy subjects were included in this study. Sera were first analysed for presence of anti-CCP antibodies and further for IgG and IgA antibodies towards candidate autoantigens in both their native and citrullinated form including: fibrinogen, alpha-enolase peptide-1 and the C1-epitope of type II collagen (C1(III)). Antibody specificity was confirmed by cross-reactivity tests. HLA-DR genotyping was performed. RESULTS: 72% of patients with RA were anti-CCP positive. Among the candidate autoantigens examined, IgG antibodies to citrullinated fibrinogen were found in 66% of patients' sera and in 41% for both citrullinated alpha-enolase peptide-1 and citrullinated C1(III). These antibodies were mainly seen in the anti-CCP-positive patient group; they were specific for their respective antigen and displayed limited cross reactivity. IgA responses were also detected, but less frequently than IgG. Anti-CCP and anti-citrullinated protein antibodies were associated with HLA-DRB1*04 rather than with HLA-DRB1*01 alleles. CONCLUSIONS: Antibodies directed against several citrullinated antigens are present in CCP-positive RA, with many patients displaying multireactivity. All specific reactivities were primarily associated with the HLA-DRB1*04 alleles, suggesting common pathways of anti-citrulline immunity.

The functional heterogeneity of eosinophil cationic protein is determined by a gene polymorphism and post-translational modifications.

BACKGROUND: The eosinophil is a cytotoxic cell and takes part in parasite killing and tissue-destructive processes by secretion of proteins such as eosinophil cationic protein (ECP). A polymorphism was demonstrated in the ECP gene, giving rise to a substitution of arginine at position 97 with threonine. This polymorphism is related to disease development. OBJECTIVE: To investigate the functional and molecular heterogeneity of native ECP and the functional consequences of the replacement of arginine with a threonine. METHODS: ECP was purified from healthy blood donors by gel filtration, ion-exchange chromatography and reversed-phase chromatography. Recombinant ECPs i.e. rECP 97(arg) and rECP 97(thr) were produced by the pFASTBAC baculovirus expression system. The cytotoxic activity was determined against an erythroleukaemia or a small cell lung cancer cell line. RESULTS: Native ECP was purified to apparent homogeneity and showed a considerable molecular heterogeneity and a corresponding functional heterogeneity with respect to cytotoxic activity. After reduction, the native cytotoxic ECP showed three bands on sodium dodecylsulphate polyacrylamide gel electrophoresis : one major band at 18-20 kDa and two minor bands at about 10 and 5 kDa, respectively. The 5 kDa contained two masses differing with 56.2 Da, which corresponds to the difference in molecular masses of arginine and threonine. rECP 97(arg) was cytotoxic in contrast to rECP97(thr). Deglycosylation with N-glycosidase F did not affect the cytotoxic activity of native ECP to any measurable extent nor the activity of rECP 97(arg), whereas rECP 97(thr) achieved cytotoxic activity. The RNase activities of the recombinant and native ECPs were similar. CONCLUSION: We conclude that ECP is present in several molecular forms with varying biological activities. Some of this functional heterogeneity is based on the genetic polymorphism of the ECP gene and some on post-translational modifications. In subjects carrying the ECP 97(thr) variant, the cytotoxic activity may be disguised by N-linked glycosylation of the active site.

Population genetics of the bovine/cattle lungworm (Dictyocaulus viviparus) based on mtDNA and AFLP marker techniques.

Mitochondrial DNA (mtDNA) sequence data and amplified fragment length polymorphism (AFLP) patterns were compared for the lungworm Dictyocaulus viviparus, a nematode parasite of cattle. Eight individual D. viviparus samples from each of 8 herds in Sweden and 1 laboratory isolate were analysed, with the aim of describing the diversity and genetic structure in populations using different genetic markers on exactly the same DNA samples. There was qualitative agreement between the whole-genome AFLP data and the mtDNA sequence data, both indicating relatively strong genetic differentiation among the Swedish farms. However, the AFLP data detected much more genetic variation than did the mtDNA data, even after allowing for the different inheritance patterns of the markers, and indicated that there was much less differentiation among the populations. The mtDNA data therefore seemed to be more informative about the most recent history of the parasite populations, as the general patterns were less obscured by detailed inter-relationships among individual worms. The 4 mtDNA genes sequenced (1542 bp) showed consistent patterns, although there was more genetic variation in the protein-coding genes than in the structural RNA genes. Furthermore, there appeared to be at least 3 distinct genetic groups of D. viviparus infecting Swedish cattle, 1 of which was predominant and showed considerable differentiation between farms, but not necessarily within farms. Second, the 2 smaller genetic groups occurred on farms where the predominant group also occurred, suggesting that these farms have had multiple introductions of D. viviparus.

Inadvertent malposition of a transvenous pacing lead in the left ventricle.

We report the case of inadvertent malpositioning of a pacemaker lead in the left ventricle. The lead went through an open foramen ovale from the right to the left atrium and through the mitral valve into the left ventricle. After a review of the literature, we decided to anticoagulate the patient and leave the electrode in place. During a follow-up period of 16 months, there were no clinical complications.

Genetic diversity assessed by amplified fragment length polymorphism analysis of the parasitic nematode Dictyocaulus viviparus the lungworm of cattle.

We have examined the population genetic structure in a collection of nine isolates of the parasitic lungworm Dictyocaulus viviparus. Eight of the isolates were sampled from cattle in geographically separated farms throughout south-central Sweden, and one isolate was a laboratory strain that has been maintained in experimentally infected calves for almost four decades. A total of 72 worms were examined, with eight individual worms from the same individual host representing each isolate. The genetic variation as revealed by amplified fragment length polymorphism analysis using four selective primer combinations was high. Depending on the primer combination a total of 66-79 restriction fragments were amplified, with 26-44 peaks of similar complexity from each of the isolates. The heterozygosity within populations was relatively small, as were the population mutation and immigration rates, which seemed to be in neutral equilibrium. The genetic diversity was therefore reasonably well structured in the field; and the laboratory isolate was quite distinct from the field samples. There was no relationship between the patterns of genetic diversity and the geographical proximity of the farms. The estimates of heterozygosity were much larger and more consistent than those previously estimated for this nematode species using mitochondrial sequencing, and the genetic structuring was thus much less pronounced and the gene flow greater. We attribute these differences in estimation to the broader sampling of loci available using amplified fragment length polymorphism markers, which may therefore constitute a superior technique for the study of patterns of lungworm diversity. Furthermore, the data estimating gene flow for D. viviparus was less than previously reported for closely related species in North America. This might be related to different rates of movements of infected hosts. It seems likely that lungworm infections are rather persistent on different farms, and the sudden outbreaks of disease that can be observed with host movements are most likely to be related to the introduction of susceptible stock.

The concept of effectiveness--a blind alley? A study of different interpretations in a Swedish county council.

Swedish health care organizations are experiencing pressure to make ever greater efforts to rationalize and to increase effectiveness in the way they plan and provide services. In order to gain a better understanding of the current practice of the three groups of key actors in Swedish health care--politicians, senior civil servants and operational managers--and their perception of effectiveness, a study was carried out in a Swedish county council using both qualitative and quantitative methods. While in general the concept of effectiveness is thought of as crucial, it is not clearly or uniformly defined within the organization. Each of the three groups defines the concept in a way that reflects their own function, which may lead efforts to achieve effectiveness into a blind alley.