Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

BACKGROUND: The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS: The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS: Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS: After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Comparing the Blood Response to Hyperbaric Oxygen with High-Intensity Interval Training-A Crossover Study in Healthy Volunteers.

High-intensity interval training (HIIT) and hyperbaric oxygen therapy (HBOT) induce reactive oxygen species (ROS) formation and have immunomodulatory effects. The lack of readily available biomarkers for assessing the dose-response relationship is a challenge in the clinical use of HBOT, motivating this feasibility study to evaluate the methods and variability. The overall hypothesis was that a short session of hyperbaric oxygen (HBO2) would have measurable effects on immune cells in the same physiological range as shown in HIIT; and that the individual response to these interventions can be monitored in venous blood and/or peripheral blood mononuclear cells (PBMCs). Ten healthy volunteers performed two interventions; a 28 min HIIT session and 28 min HBO2 in a crossover design. We evaluated bulk RNA sequencing data from PBMCs, with a separate analysis of mRNA and microRNA. Blood gases, peripheral venous oxygen saturation (SpvO2), and ROS levels were measured in peripheral venous blood. We observed an overlap in the gene expression changes in 166 genes in response to HIIT and HBO2, mostly involved in hypoxic or inflammatory pathways. Both interventions were followed by downregulation of several NF-κB signaling genes in response to both HBO2 and HIIT, while several interferon α/γ signaling genes were upregulated. Only 12 microRNA were significantly changed in HBO2 and 6 in HIIT, without overlap between interventions. ROS levels were elevated in blood at 30 min and 60 min compared to the baseline during HIIT, but not during/after HBO2. In conclusion, HBOT changed the gene expression in a number of pathways measurable in PBMC. The correlation of these changes with the dose and individual response to treatment warrants further investigation.

COVID-19-Induced Acute Respiratory Distress Syndrome Treated with Hyperbaric Oxygen: Interim Safety Report from a Randomized Clinical Trial (COVID-19-HBO).

BACKGROUND: A few prospective trials and case series have suggested that hyperbaric oxygen therapy (HBOT) may be efficacious for the treatment of severe COVID-19, but safety is a concern for critically ill patients. We present an interim analysis of the safety of HBOT via a randomized controlled trial (COVID-19-HBO). METHODS: A randomized controlled, open-label, clinical trial was conducted in compliance with good clinical practice to explore the safety and efficacy of HBOT for severe COVID-19 in critically ill patients with moderate acute respiratory distress syndrome (ARDS). Between 3 June 2020, and 17 May 2021, 31 patients with severe COVID-19 and moderate-to-severe ARDS, a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) < 26.7 kPa (200 mmHg), and at least two defined risk factors for intensive care unit (ICU) admission and/or mortality were enrolled in the trial and randomized 1:1 to best practice, or HBOT in addition to best practice. The subjects allocated to HBOT received a maximum of five treatments at 2.4 atmospheres absolute (ATA) for 80 min over seven days. The subjects were followed up for 30 days. The safety endpoints were analyzed. RESULTS: Adverse events (AEs) were common. Hypoxia was the most common adverse event reported. There was no statistically significant difference between the groups. Numerically, serious adverse events (SAEs) and barotrauma were more frequent in the control group, and the differences between groups were in favor of the HBOT in PaO2/FiO2 (PFI) and the national early warning score (NEWS); statistically, however, the differences were not significant at day 7, and no difference was observed for the total oxygen burden and cumulative pulmonary oxygen toxicity dose (CPTD). CONCLUSION: HBOT appears to be safe as an intervention for critically ill patients with moderate-to-severe ARDS induced by COVID-19. CLINICAL TRIAL REGISTRATION: NCT04327505 (31 March 2020) and EudraCT 2020-001349-37 (24 April 2020).

Hyperbaric oxygen therapy for long COVID (HOT-LoCO), an interim safety report from a randomised controlled trial.

BACKGROUND: With ~ 50 million individuals suffering from post-COVID condition (PCC), low health related quality of life (HRQoL) is a vast problem. Common symptoms of PCC, that persists 3 months from the onset of COVID-19 are fatigue, shortness of breath and cognitive dysfunction. No effective treatment options have been widely adopted in clinical practice. Hyperbaric oxygen (HBO2) is a candidate drug. METHODS: The objective of this interim analysis is to describe our cohort and evaluate the safety of HBO2 for post covid condition. In an ongoing randomised, placebo-controlled, double blind, clinical trial, 20 previously healthy subjects with PCC were assigned to HBO2 or placebo. Primary endpoints are physical domains in RAND-36; Physical functioning (PF) and Role Physical (RP) at 13 weeks. Secondary endpoints include objective physical tests. Safety endpoints are occurrence, frequency, and seriousness of Adverse Events (AEs). An independent data safety monitoring board (DSMB) reviewed unblinded data. The trial complies with Good Clinical Practice. Safety endpoints are evaluated descriptively. Comparisons against norm data was done using t-test. RESULTS: Twenty subjects were randomised, they had very low HRQoL compared to norm data. Mean (SD) PF 31.75 (19.55) (95% Confidence interval; 22.60-40.90) vs 83.5 (23.9) p < 0.001 in Rand-36 PF and mean 0.00 (0.00) in RP. Very low physical performance compared to norm data. 6MWT 442 (180) (95% CI 358-525) vs 662 (18) meters p < 0.001. 31 AEs occurred in 60% of subjects. In 20 AEs, there were at least a possible relationship with the study drug, most commonly cough and chest pain/discomfort. CONCLUSIONS: An (unexpectedly) high frequency of AEs was observed but the DSMB assessed HBO2 to have a favourable safety profile. Our data may help other researchers in designing trials. Trial Registration ClinicalTrials.gov: NCT04842448. Registered 13 April 2021, https://clinicaltrials.gov/ct2/show/NCT04842448 . EudraCT: 2021-000764-30. Registered 21 May 2021, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-000764-30/SE.

Hyperbaric oxygen for treatment of long COVID-19 syndrome (HOT-LoCO): protocol for a randomised, placebo-controlled, double-blind, phase II clinical trial.

INTRODUCTION: Long COVID-19, where symptoms persist 12 weeks after the initial SARS-CoV-2-infection, is a substantial problem for individuals and society in the surge of the pandemic. Common symptoms are fatigue, postexertional malaise and cognitive dysfunction. There is currently no effective treatment and the underlying mechanisms are unknown, although several hypotheses exist, with chronic inflammation as a common denominator. In prospective studies, hyperbaric oxygen therapy (HBOT) has been suggested to be effective for the treatment of similar syndromes such as chronic fatigue syndrome and fibromyalgia. A case series has suggested positive effects of HBOT in long COVID-19. This randomised, placebo-controlled clinical trial will explore HBOT as a potential treatment for long COVID-19. The primary objective is to evaluate if HBOT improves health-related quality of life (HRQoL) for patients with long COVID-19 compared with placebo/sham. The main secondary objective is to evaluate whether HBOT improves endothelial function, objective physical performance and short-term HRQoL. METHODS AND ANALYSIS: A randomised, placebo-controlled, double-blind, phase II clinical trial in 80 previously healthy subjects debilitated due to long COVID-19, with low HRQoL. Clinical data, HRQoL questionnaires, blood samples, objective tests and activity metre data will be collected at baseline. Subjects will be randomised to a maximum of 10 treatments with hyperbaric oxygen or sham treatment over 6 weeks. Assessments for safety and efficacy will be performed at 6, 13, 26 and 52 weeks, with the primary endpoint (physical domains in RAND 36-Item Health Survey) and main secondary endpoints defined at 13 weeks after baseline. Data will be reviewed by an independent data safety monitoring board. ETHICS AND DISSEMINATION: The trial is approved by the Swedish National Institutional Review Board (2021-02634) and the Swedish Medical Products Agency (5.1-2020-36673). Positive, negative and inconclusive results will be published in peer-reviewed scientific journals with open access. TRIAL REGISTRATION NUMBER: NCT04842448.

Lemierre's syndrome caused by Fusobacterium necrophorum complicated with multiple brain abscesses-A case report, literature review, and suggested management.

We present an unusual case of Lemierre´s syndrome complicated by multiple brain abscesses, a literature review and suggested management. A young man with multiple brain abscesses deteriorated despite two weeks of directed antibiotics. A multidisciplinary approach was successful. Hyperbaric oxygen treatment (HBOT) should be considered in refractory or severe cases.

Randomised, controlled, open label, multicentre clinical trial to explore safety and efficacy of hyperbaric oxygen for preventing ICU admission, morbidity and mortality in adult patients with COVID-19.

INTRODUCTION: COVID-19 may cause severe pneumonitis and trigger a massive inflammatory response that requires ventilatory support. The intensive care unit (ICU)-mortality has been reported to be as high as 62%. Dexamethasone is the only of all anti-inflammatory drugs that have been tested to date that has shown a positive effect on mortality. We aim to explore if treatment with hyperbaric oxygen (HBO) is safe and effective for patients with severe COVID-19. Our hypothesis is that HBO can prevent ICU admission, morbidity and mortality by attenuating the inflammatory response. The primary objective is to evaluate if HBO reduces the number of ICU admissions compared with best practice treatment for COVID-19, main secondary objectives are to evaluate if HBO reduces the load on ICU resources, morbidity and mortality and to evaluate if HBO mitigates the inflammatory reaction in COVID-19. METHODS AND ANALYSIS: A randomised, controlled, phase II, open label, multicentre trial. 200 subjects with severe COVID-19 and at least two risk factors for mortality will be included. Baseline clinical data and blood samples will be collected before randomisation and repeated daily for 7 days, at days 14 and 30. Subjects will be randomised with a computer-based system to HBO, maximum five times during the first 7 days plus best practice treatment or only best practice treatment. The primary endpoint, ICU admission, is defined by criteria for selection for ICU. We will evaluate if HBO mitigates the inflammatory reaction in COVID-19 using molecular analyses. All parameters are recorded in an electronic case report form. An independent Data Safety Monitoring Board will review the safety parameters. ETHICS AND DISSEMINATION: The trial is approved by The National Institutional Review Board in Sweden (2020-01705) and the Swedish Medical Product Agency (5.1-2020-36673). Positive, negative and any inconclusive results will be published in peer-reviewed scientific journals with open access. TRIAL REGISTRATION: NCT04327505. EudraCT number: 2020-001349-37.

Can hyperbaric oxygen safely serve as an anti-inflammatory treatment for COVID-19?

INTRODUCTION: SARS-CoV-2 affects part of the innate immune response and activates an inflammatory cascade stimulating the release of cytokines and chemokines, particularly within the lung. Indeed, the inflammatory response during COVID-19 is likely the cause for the development of acute respiratory distress syndrome (ARDS). Patients with mild symptoms also show significant changes on pulmonary CT-scan suggestive of severe inflammatory involvement. HYPOTHESIS: The overall hypothesis is that HBO2 is safe and reduces the inflammatory response in COVID-19 pneumonitis by attenuation of the innate immune system, increase hypoxia tolerance and thereby prevent organ failure and reduce mortality. EVALUATION OF THE HYPOTHESIS: HBO2 is used in clinical practice to treat inflammatory conditions but has not been scientifically evaluated for COVID-19. Experimental and empirical data suggests that HBO2 may reduce inflammatory response in COVID-19. However, there are concerns regarding pulmonary safety in patients with pre-existing viral pneumonitis. EMPIRICAL DATA: Anecdotes from "compassionate use" and two published case reports show promising results. CONSEQUENCES OF THE HYPOTHESIS AND DISCUSSION: Small prospective clinical trials are on the way and we are conducting a randomized clinical trial.

Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2-3 trial.

BACKGROUND: Late radiation cystitis is an adverse effect of cancer treatment with radiotherapy in the pelvic region. Symptoms of late radiation cystitis can be assessed with the Expanded Prostate Index Composite Score (EPIC). Previous reports indicate that hyperbaric oxygen therapy reduces symptoms from late radiation cystitis, but the evidence is predominantly based on non-randomised and retrospective studies. We aimed to assess whether hyperbaric oxygen therapy would mitigate symptoms of late radiation cystitis. METHODS: We did a randomised, controlled, phase 2-3 trial (RICH-ART [Radiation Induced Cystitis treated with Hyperbaric oxygen-A Randomised controlled Trial]) at five Nordic university hospitals. All patients aged 18-80 years, with pelvic radiotherapy completed at least 6 months previously, a score of less than 80 in the urinary domain of the Expanded Prostate Index Composite Score (EPIC), and referred to participating hyperbaric clinics due to symptoms of late radiation cystitis, were eligible for inclusion. Exclusion criteria were ongoing bleeding requiring blood transfusion exceeding 500 mL in the past 4 weeks, permanent urinary catheter, bladder capacity less than 100 mL, fistula in the urinary bladder, previous treatment with hyperbaric oxygen therapy for late radiation injuries, and contraindications to hyperbaric oxygen therapy. After computer-generated 1:1 randomisation with block sizes of four for each stratification group (sex, time from radiotherapy to inclusion, and previous invasive surgery in the pelvic area), patients received hyperbaric oxygen therapy (30-40 sessions, 100% oxygen, breathed at a pressure of 240-250 kPa, for 80-90 min daily) or standard care with no restrictions for other medications or interventions. No masking was applied. The primary outcome was change in patient-perceived urinary symptoms assessed with EPIC from inclusion to follow-up at visit 4 (6-8 months later), measured as absolute change in EPIC urinary total score. RICH-ART closed enrolment on Dec 31, 2017; the last follow-up data will be compiled in 2023. RICH-ART is registered with ClinicalTrials.gov, number NCT01659723, and with the European Medicines Agency, number EudraCT 2012-001381-15. FINDINGS: Of 223 patients screened between May 9, 2012, and Dec 20, 2017, 87 patients were enrolled and randomly assigned to either hyperbaric oxygen therapy (n=42) or standard care (n=45). After excluding eight patients who withdrew consent directly after randomisation (one in the hyperbaric oxygen therapy group and seven in the standard care group), 79 were included in the intention-to-treat analyses (n=41 in the hyperbaric oxygen therapy group, n=38 in the standard care group). Median time from randomisation to visit 4 was 234 days (IQR 210-262) in the hyperbaric oxygen therapy group and 217 days (195-237) in the standard care group. The difference between change in group mean of EPIC urinary total score at visit 4 was 10·1 points (95% CI 2·2-18·1; p=0·013; 17·8 points [SD 18·4] in the hyperbaric oxygen therapy group vs 7·7 points [15·5] in the standard care group). 17 (41%) of 41 patients in the hyperbaric oxygen therapy group experienced transient grade 1-2 adverse events, related to sight and hearing, during the period of hyperbaric oxygen therapy. INTERPRETATION: Our results suggest that hyperbaric oxygen therapy relieves symptoms of late radiation cystitis. We conclude that hyperbaric oxygen therapy is a safe and well tolerated treatment. FUNDING: The regional research fund of Region Västra Götaland, Sweden, the regional Health Technology Assessment Centre at Sahlgrenska University Hospital, Sweden, and Lions Cancer Research Fund of Western Sweden.

Massive air embolism as a complication of upper gastrointestinal endoscopy: A case report illustrating a stroke mimic, literature review, and suggested management.

Cerebral air embolism should be considered in case of stroke symptoms during any invasive procedure. Transport to a hospital with neurosurgical/hyperbaric oxygen treatment (HBOT) facility could improve the outcome for the patient. Absence of air on computed tomography (CT) scan should not disqualify a patient from HBOT if air embolism is suspected.

Speech intelligibility and recall of first and second language words heard at different signal-to-noise ratios.

Free recall of spoken words in Swedish (native tongue) and English were assessed in two signal-to-noise ratio (SNR) conditions (+3 and +12 dB), with and without half of the heard words being repeated back orally directly after presentation [shadowing, speech intelligibility (SI)]. A total of 24 word lists with 12 words each were presented in English and in Swedish to Swedish speaking college students. Pre-experimental measures of working memory capacity (operation span, OSPAN) were taken. A basic hypothesis was that the recall of the words would be impaired when the encoding of the words required more processing resources, thereby depleting working memory resources. This would be the case when the SNR was low or when the language was English. A low SNR was also expected to impair SI, but we wanted to compare the sizes of the SNR-effects on SI and recall. A low score on working memory capacity was expected to further add to the negative effects of SNR and language on both SI and recall. The results indicated that SNR had strong effects on both SI and recall, but also that the effect size was larger for recall than for SI. Language had a main effect on recall, but not on SI. The shadowing procedure had different effects on recall of the early and late parts of the word lists. Working memory capacity was unimportant for the effect on SI and recall. Thus, recall appear to be a more sensitive indicator than SI for the acoustics of learning, which has implications for building codes and recommendations concerning classrooms and other workplaces, where both hearing and learning is important.

Measures against preschool noise and its adverse effects on the personnel: an intervention study.

PURPOSE: The aim of the study was to analyze the exposure effects of different types of noise measures carried out at preschools. The project was carried out as an intervention study. METHODS: The investigation included 89 employees at 17 preschools in the northern part of Sweden. Individual noise recordings and recordings in dining rooms and play halls were made at two departments in each preschool. The adverse effects on the employees were analyzed with validated questionnaires and saliva cortisol samples. Evaluations were made before and 1 year after the first measurement. Between the two measurements, measures were taken to improve the sound environments at the preschools. RESULTS: The effects of the measures varied a lot, with respect to both the sound environments and health. Regarding acoustical measures, significant changes were seen for some of the variables analyzed. For most of the tested effects, the changes, however, were very small and non-significant. The effects of organizational measures on the objective and subjective noise values were in overall less pronounced. CONCLUSION: Acoustical measures improved the subjectively rated sound environment more than organizational measures. This may be due to the high work effort needed to implement organizational measures. Even though the sound level was not lower, the personnel experienced improvements of the sound environment.

Can people with disabilities gain from education? Similarities and differences between occupational attainment among persons with and without disabilities.

BACKGROUND: More knowledge is needed of occupational attainment of persons with disabilities, i.e., the relationship between their educational level and their profession, and factors of importance for this relationship. OBJECTIVE: To compare occupational attainment among persons with and without a disability. METHOD: 3396 informants with disabilities and 19,004 non-disabled informants participated (control group) in a survey study by Statistics Sweden.The informants with disabilities were divided into six groups. RESULTS: Occupational attainment did not differ between the disability groups, neither between persons with and without a disability. Follow-up analysis showed that men with disabilities with primary or secondary school had an occupation above their educational level to a significantly larger extent than women with disabilities. This pattern was even clearer in comparison with the control group. Persons without disabilities, with secondary or higher education, were more successful in the labor market than persons with disabilities. Occupational attainment increased with age in both groups. CONCLUSIONS: Young women with disabilities who only have primary or secondary education run a higher risk of having a job that is below their educational level than men at the same educational level. This indicates discriminating mechanisms in the society related to gender and ability.

Noise and stress effects on preschool personnel.

The aim of the study was to analyze the presence of stress-related health problems among preschool employees and the way in which these reactions are related to noise and other work parameters. The investigation included 101 employees at 17 preschools in Umeå County, located in northern Sweden. Individual noise recordings and recordings in dining rooms and play halls were made at two departments from each preschool. The adverse effects on the employees were analyzed by use of different validated questionnaires and by saliva cortisol samples. Stress and energy output were pronounced among the employees, and about 30% of the staff experienced strong burnout syndromes. Mental recovery after work was low, indicated by remaining high levels of stress after work. The burnout symptoms were associated with reduced sleep quality and morning sleepiness. Cortisol levels supported the conclusion about pronounced daily stress levels of the preschool employees.

Noise exposure and auditory effects on preschool personnel.

Hearing impairments and tinnitus are being reported in an increasing extent from employees in the preschool. The investigation included 101 employees at 17 preschools in Umeå county, Sweden. Individual noise recordings and stationary recordings in dining rooms and play halls were conducted at two departments per preschool. The effects of noise exposures were carried out through audiometric screenings and by use of questionnaires. The average individual noise exposure was close to 71 dB(A), with individual differences but small differences between the preschools. The noise levels in the dining room and playing halls were about 64 dB(A), with small differences between the investigated types of rooms and preschools. The hearing loss of the employees was significantly higher for the frequencies tested when compared with an unexposed control group in Sweden. Symptoms of tinnitus were reported among about 31% of the employees. Annoyance was rated as somewhat to very annoying. The voices of the children were the most annoying noise source. The dB(A) level and fluctuation of the noise exposure were significantly correlated to the number of children per department. The preschool sound environment is complex and our findings indicate that the sound environment is hazardous regarding auditory disorders. The fluctuation of the noise is of special interest for further research.

Stress, energy and psychosocial conditions in different types of call centres.

OBJECTIVE: To identify risk indicators for high stress and low mental energy as well as to describe psychosocial working conditions at different types of call centres. PARTICIPANTS: 1183 operators from 28 call centres in Sweden, both external and internal, with different levels of task complexity, ownership and geographical location. METHOD: A cross sectional questionnaire study. RESULTS: The stress level was moderately high and the energy level fairly high. Stress levels tended to be lower and psychosocial conditions better with increasing level of task complexity. Fourteen per cent of the operators were in a state of high stress/low energy ("worn out") and 47% in high stress/high energy ("committed under pressure"). Operators in a state of low stress/high energy ("committed without pressure") were most likely to report a better health status. High stress and lack of energy was mainly associated with time pressure, low decision latitude, and lack of social and supervisor support. CONCLUSIONS: Time pressure in combination with lack of support and influence should be seen as a potential high risk situation for the development of a "worn-out" state among call centre operators. Management should make use of this knowledge in order to promote a long lasting efficient and healthy call centre work.

Stability and change in work values among male and female nurses and engineers.

Gender related changes of work values were analyzed in a longitudinal questionnaire study of 173 male and 48 female engineers and 353 female and 31 male nurses at three measurement occasions covering about four and half years from the end of their vocational education. At all occasions, Social relations were rated as more important by women than by men and Altruism was given higher ratings by the nurses than by the engineers. Within both occupations women's mean Altruism ratings were higher than men's mean ratings, and in all groups except male engineers the mean ratings dropped between the three occasions. Women's ratings of Benefits and career and Influence were strengthened in both occupations, thereby eliminating an initial gender difference. The stability of work values is discussed in terms of challenges and norms in working life.

Evaluation of nursing students' work technique after proficiency training in patient transfer methods during undergraduate education.

UNLABELLED: The aim of this study was to investigate if nursing students improved their work technique when assisting a simulated patient from bed to wheelchair after proficiency training, and to investigate whether there was a correlation between the nursing students' work technique and the simulated patients' perceptions of the transfer. METHOD: 71 students participated in the study, 35 in the intervention group and 36 in the comparison group. The students assisted a simulated patient to move from a bed to a wheelchair. In the intervention group the students made one transfer before and one after training, and in the comparison group they made two transfers before training. Six variables were evaluated: work technique score; nursing students' ratings of comfort, work technique and exertion, and the simulated patients' perceptions of comfort and safety during the transfer. The result showed that nursing students improved their work technique, and that there was a correlation between the work technique and the simulated patients' subjective ratings of the transfer. In conclusion, nursing students improved their work technique after training in patient transfer methods, and the work technique affected the simulated patients' perceptions of the transfer.

A direct observation instrument for assessment of nurses' patient transfer technique (DINO).

The aim of this project was to develop a direct observation instrument to assess the work technique of nursing personnel during patient transfers and to test the validity and reliability of the instrument. An expert group developed this instrument, called DINO (DIrect Nurse Observation instrument for assessment of work technique during patient transfers), which contains 16 items divided into three phases of a transfer: the preparation, performance and result phases. To quantify the assessments a scoring system was constructed, giving an overall score for each transfer, depending on the level of musculoskeletal health and safety. Four observers assessed 45 patient transfers at hospital wards and showed in an evaluation that the inter-observer reliability and criterion-related validity of DINO was satisfactory. The assessments with the DINO instrument are done directly when the transfer occurs, without costly equipment. Therefore, it has a wide range of applications. For example, when evaluating training in work technique or when identifying an unsafe work technique as a risk factor for musculoskeletal problems in epidemiological studies.