Training of transport drivers improves their handling of pigs during loading for transport to slaughter.

Pig transport drivers' (TDs') handling actions are of great importance as these drivers handle a large number of finishing pigs during stressful situations. Poor handling techniques can have negative consequences for working conditions, pig welfare and meat quality. We studied the effects of a training intervention on Swedish TDs' attitudes towards pigs and their handling actions during loading for transport to slaughter. Twenty TDs working with commercial pig transportation in Sweden were recruited and completed an attitude questionnaire. Ten of them were observed during one loading of pigs before training, and one or two loadings after training (49-265 pigs per loading), and eight of them completed the attitude questionnaire again 50-160 days after training. The cognitive-behavioural training program ProHand Pigs® was adapted and delivered to the ten TDs during a group session, followed by individual meetings. TDs' handling actions were video recorded and summarised as binary variables per 5-s interval. Factor analysis, principal component analysis and paired t-test were conducted to investigate the effects of the training intervention on TDs' attitudes, and mixed-effects logistic models were used to examine effects on negative and positive handling actions. Training tended to decrease TDs' beliefs that it is important to move pigs quickly (P = 0.095). Training decreased the odds of a 'moderately to strongly negative' action by 55% (P = 0.0013) and increased the odds of a 'positive' action by 97% (P < 0.0001). This study provides valuable insights into the possibilities to improve TDs' handling actions, and implications for pig welfare during slaughter transport. The study supports previous findings that the attitudes and behaviour of handlers can be improved by cognitive-behavioural training. While our previous research has shown reciprocal relationships between TDs' actions and pig behaviour, further research on TDs' attitudes towards handling that underlie the nature of their behaviour when handling pigs is necessary to fine-tune the cognitive-behavioural training program applied in the present study.

Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life.

Background: During pregnancy, women are at risk of developing persistent symptomatic diastasis recti abdominis (DRA), which may have a detrimental effect on their physical function and quality of life (QoL). The aim of this prospective cohort study was to determine the effect of surgical repair of DRA on abdominal trunk function, urinary incontinence and QoL in postpartum women with trunk instability symptoms resistant to training. Methods: Postpartum women with diagnosed DRA and training-resistant symptoms underwent double-row plication of the linea alba. Abdominal trunk function was evaluated as the primary endpoint using a multimodal examination tool, the Abdominal Trunk Function Protocol. Recurrence was assessed by CT, urinary incontinence was evaluated using the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), and QoL was assessed with the Short Form 36 (SF-36®) questionnaire. All subjects were examined before and 1 year after surgery. Results: Sixty women were recruited. There was no DRA recurrence at the 1-year follow-up. Self-reported abdominal trunk function had improved in 98 per cent of patients, with a mean score improvement of 79·1 per cent. In the physiological tests monitored by a physiotherapist, 76 per cent performed better and endured exercise tests longer than before surgery. All SF-36® subscales improved significantly compared with preoperative scores and reached levels similar to, or higher than, the normative Swedish female population. For the UDI-6 and IIQ-7, 47 and 37 per cent respectively reported fewer symptoms at follow-up than before surgery, and 13 and 8 per cent respectively reported more symptoms. Conclusion: In this series of postpartum women presenting with DRA and symptoms of trunk instability resistant to training, surgical reconstruction resulted in a significant improvement in abdominal trunk function, urinary incontinence and QoL.

Antecedentes: Durante el embarazo, las mujeres tienen el riesgo de desarrollar una diástasis rectoabdominal persistente y sintomática (diastasis rectoabdominis, DRA) que puede tener un efecto perjudicial en su función física y en la calidad de vida (quality of life, QoL). El objetivo de este estudio de cohortes prospectivo fue determinar el efecto de reparación quirúrgica de la DRA en la función de la musculatura de la pared abdominal, la incontinencia urinaria y la QoL en mujeres con síntomas postparto de inestabilidad de la musculatura abdominal resistentes al entrenamiento. Métodos: Sesenta mujeres diagnosticadas en el postparto de DRA y con síntomas resistentes al entrenamiento se sometieron a una plicatura de doble capa de la línea alba. El objetivo primario fue evaluar la función de la musculatura de la pared abdominal mediante una herramienta de examen multimodal, el protocolo de la función de la pared abdominal (abdominal trunk function protocol, ATFP). La recidiva se evaluó mediante tomografía computarizada, la incontinencia urinaria utilizando los cuestionarios UDI­6 y IIQ­7 y la calidad de vida con el cuestionario SF­36. Todas las participantes fueron examinadas antes de la cirugía y un año después de la misma. Resultados: Tras un año de seguimiento, no hubo recidiva de la DRA. Según informaron las pacientes, la función de la musculatura abdominal había mejorado en el 98,2% de los casos, con una mejoría en la puntuación media del 79,1%. En las pruebas fisiológicas controladas por un fisioterapeuta, el 76,0% presentó mejoría y aumentó la duración en las pruebas de resistencia en comparación con antes de la cirugía. Todas las subescalas del SF­36 mejoraron significativamente en comparación con las puntuaciones preoperatorias y alcanzaron niveles similares o superiores a los de la población femenina sueca normal. Para el UDI­6 y el IIQ­7, el 46,7% y el 36,7% respectivamente, manifestaron menos síntomas en el seguimiento que antes de la cirugía, mientras que el 13,3% y el 8,3% respectivamente, reportaron más síntomas. Conclusión: En esta serie de mujeres que presentan DRA en el posparto y síntomas de inestabilidad de la musculatura abdominal resistente al entrenamiento, la reconstrucción quirúrgica produjo una mejora significativa en la función de la musculatura abdominal, la incontinencia urinaria y la calidad de vida.

A multifaceted intervention model can give a lasting improvement of older peoples' nutritional status.

OBJECTIVE: The purpose of this study was with a multifaceted intervention model improve the nutritional status of elderly people living in residential homes to increase their energy intake and to maintain improvements over time. SETTING: Three different municipal residential homes in the south-east of Sweden. PARTICIPANTS: The study population consisted of 67 elderly people. A within-subjects design was used which means that the participants were their own controls. INTERVENTION: A multifaceted intervention model was chosen, which included education on both theoretical and practical issues, training and support for staff, and individualized snacks to the residents. MEASUREMENTS: Nutritional status was measured by Mini Nutritional Assessment (MNA), the consumption of food was recorded by the staff using a food record method for 3 consecutive days. The length of night-time fasting has been calculated from the food records. RESULTS: Nutritional status improved after 3 months of intervention and was maintained after 9 months. Weight increased during the whole study period. Night-time fasting decreased but not to the recommended level. CONCLUSION: This study shows that it is possible by a multifaceted intervention model to increase energy intake including expanding snacks and thereby improve and maintain nutritional status over a longer period in the elderly living in residential homes. This result was possible to achieve because staff received education and training in nutritional issues and by provision of support during a period when new routines were introduced.

Nutritional status and health care costs for the elderly living in municipal residential homes--an intervention study.

OBJECTIVE: The aim was to study the effect of individualised meals on nutritional status among older people living in municipal residential homes and to compare the results with a control group. An additional aim was to estimate direct health care costs for both groups. SETTING: Six different municipal residential homes in the south-east of Sweden. PARTICIPANTS: Older people living in three residential homes constituted the intervention group n=42 and the rest constituted the control group n=67. INTERVENTION: A multifaceted intervention design was used. Based on an interview with staff a tailored education programme about nutritional care, including both theoretical and practical issues, was carried through to staff in the intervention group. Nutritional status among the elderly was measured by Mini Nutritional Assessment (MNA), individualised meals were offered to the residents based on the results of the MNA. Staff in the control group only received education on how to measure MNA and the residents followed the usual meal routines. MEASUREMENTS: Nutritional status was measured by MNA at baseline and after 3 months. Cost data on health care visits during 2007 were collected from the Cost Per Patient database. RESULTS: Nutritional status improved and body weight increased after 3 months in the intervention group. Thus, primary health care costs constituted about 80% of the total median cost in the intervention group and about 55% in the control group. CONCLUSION: With improved knowledge the staff could offer the elderly more individualised meals. One of their future challenges is to recognise and assess nutritional status among this group. If malnutrition could be prevented health care costs should be reduced.

Quality of nursing care from the perspective of patients with leg ulcers.

OBJECTIVE: To investigate and analyse the quality of nursing care in a primary care setting from the perspective of patients with leg ulcers and determine the subjective importance that patients attach to various aspects of quality of care. METHOD: All of the patients with leg ulcers at 15 primary care centres in the south east of Sweden were invited to participate. They were given the short version of the Quality from the Patient's Perspective questionnaire (QPP) to fill in. This included a number of closed and open questions relating to their perceptions of the quality of their nursing care and the importance of this care to them. RESULTS: Overall, the patients in this study perceived that the quality of nursing care was high. However, important areas for improvement were revealed, including the need for an increase in patient-focused care, continuity of care and better pain relief. CONCLUSION: To address the weak points highlighted by the study, we recommend that nurses explore patient perceptions of pain in greater detail and invite patients take a more active role in the management of their leg ulcers.

National public health target awareness of staff at two organisational levels in health care

OBJECTIVE: To investigate national public health target awareness at two organisational levels in health care comprising public officials and district nurses (DNs). To determine if the targets were incorporated in county council public health policy documents and if DNs worked in accordance with them. METHOD: Telephone interviews were performed with 21 county council officials and personal interviews were conducted with 54 DNs representing Sweden's 21 health care regions. RESULTS: Sixteen officials reported that their county council had documented public health programs, and in 13, some of the national targets were incorporated. Primary care was given major responsibility for public health. Two programs mentioned DNs' work. The officials said prevention should focus on all age groups and they emphasised the importance of health promotion. The DNs did not mention the national targets for public health and rarely mentioned targets at the county council level. Their work with prevention included self-care advice, changes in lifestyle, and preventing and relieving consequences of chronic disease. The DNs considered themselves as key persons in this work. CONCLUSIONS: The results reflect difficulties in implementing national targets and the existence of communication problems between political authorities, public officials, and doers. Preventive work is nevertheless done in relevant areas. (AU)

Opinions about district nurses prescribing.

Opinions about district nurses prescribing The aim of this study was to investigate the opinions of district nurses (DNs) and general practitioners (GPs) about nurse prescribing in Sweden in order to elucidate similarities and differences, and relate different opinions to background and psychosocial working factors. In a questionnaire about psychosocial working conditions, seven statements about DNs prescribing were included. The questionnaire was sent to 554 DNs and 566 GPs with a participant rate of 83%. On all items as well as on the total score DNs rated more positively compared with GPs. Amongst the DNs a positive opinion was related to a traditional primary care organization, age < 50, good social support at work, and high workload. A positive opinion amongst GPs was associated with working in a traditional primary care organization, being male GP, and a good social support at work. In a multiple regression analysis, occupation and organization were independently associated with the total score. The result shows a strong professional solidarity amongst GPs and seems to be based on concern about the profession rather than patient care.

Assessment of psychosocial work environment in primary care--development of a questionnaire.

Recent studies have indicated deteriorated working conditions of health care personnel. To have an efficient health care organization requires good working conditions and the well-being of the personnel. Today there are no "gold-standard" assessment tools measuring psychosocial working conditions. The aim of this study was to develop two valid and reliable questionnaires, one generic and one specific, measuring psychosocial working conditions for general practitioners (GPs) and district nurses (DNs) in Sweden, with a special emphasis on organizational changes. The construction of the questionnaires were made after a stepwise developing phase including literature review, interviews, and a pilot study. The pilot study included GPs n = 42 and DNs n = 39. The questionnaires were later on used in a main study (GPs n = 465, DNs n = 465). A factor analysis was carried out and showed that there were fewer items in the main study that had factor loading > or = 0.40 in more than one factor, compared to the pilot study. The factors from the main study were easier to label and had good correspondence with other studies. After this stepwise development phase good construct validity and internal consistency were established for the questionnaire.

One-month versus six-month therapy with oral anticoagulants after symptomatic deep vein thrombosis.

The length of time for which deep vein thrombosis (DVT) should be treated with oral anticoagulants (OA) is controversial. In this study, 135 patients with symptomatic first period DVT (83% with proximal DVT) were randomly allocated to OA for one or six months. The diagnosis of initial and recurrent DVT was confirmed by phlebography or plethysmography and thermography, or by a combination of all these methods. Pulmonary emboli were confirmed by lung scans or at autopsy. The patients were followed for at least one year. One patient had to discontinue OA prematurely because of haemorrhage. Seventeen patients left the project for other reasons, ten during and seven after therapy; in one of these DVT recurred. The recurrence rate during the first year was high (17% symptomatic recurrences) irrespective of whether OA had been given for one or six months.

Heparin elimination and hemostasis in hemodialysis.

The heparin concentrations at the end of dialysis and the post-dialysis hemostasis were studied in 16 patients in a chronic hemodialysis program. In 8 of the patients, the heparin half-life values after dialysis were determined as well. The heparin doses were calculated as 90 IU/kg body-weight, administered in a standardized way. The heparin concentrations and the half-life values varied between 0.12-0.94 IU/ml and 29-114 minutes respectively, indicating that the heparin administration must be individually modelled. The hemostasis, measured by the arterial pressure times, was positively correlated to the heparin concentrations. Heparin levels less than 0.3 IU/ml were regularly associated with pressure times less than 10 minutes and no remaining heparin activity two hours after dialysis. In order to minimize the risk of both bleeding and clotting complications at the end of and after dialysis, a heparin concentration of approximately 0.25 IU/ml should be aimed for.

Antithrombin III in patients with acute deep vein thrombosis during heparin treatment (subcutaneous and intravenous) and during and after treatment with oral coumarins.

The antithrombin III (AT-III) concentration was studied in 98 patients with symptomatic acute deep-vein thrombosis. All patients were initially treated with heparin randomly by subcutaneous injections or by continuous infusions. Then the patients were treated with coumarins during one or six months. The AT-III concentration was estimated daily during heparin treatment and repeatedly during the first year. The mean AT-III concentration decreased progressively 25% during 5 days of heparin treatment regardless of whether heparin was given intravenously or subcutaneously. The mean AT-III concentration during coumarin treatment was higher than after coumarin treatment. Eleven patients developed recurrent thromboembolic episodes during the follow-up period. The mean AT-III concentration in these patients was not lower than in the patients without recurrences.

Thrombin activity during hemodialysis; evaluated by the fibrinopeptide A assay. A comparison between a high and a low heparin dose regime.

Ten patients participated in this study which evaluated the effect of two heparin dose regimes, a high dose regime (mean dose 6750 IU) and a low dose regime (mean dose 3750 IU), on the thrombin activity, achieved during a 4-hour-dialysis. The thrombin activity was measured by use of the FPA assay. Heparin was administered as bolus dose followed by a constant rate infusion which was discontinued 1.5-2 hours prior to the end of the dialysis. Both dose regimes inhibited thrombin activity equally effectively as long as heparin was administered. In the high dose regime, the FPA levels remained unchanged until the end of the dialyses in all patients. In the low dose regime, six patients had the same FPA values at the end of the heparin infusion and at the end of the dialysis. In the remaining four patients much higher FPA levels were achieved at the end of the dialysis. No serious bleeding or clotting complications occurred, and all dialyses were uneventful.

Whole-blood activated coagulation time for evaluation of heparin activity during hemodialysis: a comparison of administration by single-dose and by infusion.

Whole-blood activated coagulation time (WBACT), measured by an automated technique, was used to estimate heparin activity in 12 patients in a chronic hemodialysis program. Identical heparin doses, calculated on a body-weight basis, were given to each patient, either as a single dose before a 3.5-4 hour dialysis, or as a loading dose followed by infusion during the first 1.5-2 hours of dialysis. Each dose regimen was repeated during four consecutive dialyses. The variation in heparin activity between the four dialyses did not exceed the standard deviation of the WBACT method. This indicates that the heparin requirement between dialyses was steady. Appreciable interindividual differences in heparin activity were found, however, showing that heparin requirement cannot be determined solely on a body-weight basis. Fibrin deposits in the venous drip chamber were uncommon during the first two hours but became more frequent towards the end of dialysis, the increase being significantly more with the single-dose than with the infusion regimen. Maintenance of heparin activity at the end of dialysis was better with the infusion regimen. Prolonged heparin infusion is preferable to single-dose injection to maintain the heparin effect and prevent fibrin deposits.

Subcutaneous administration of heparin. A randomised comparison with intravenous administration of heparin to patients with deep-vein thrombosis.

One-hundred and forty-one patients with clinical signs of acute deep venous thrombosis (DVT) in the legs were randomly allocated to receive heparin either as two daily subcutaneous injections (s.c.) or as continuous intravenous infusion (i.v.). The thrombi extended into the popliteal or femoral veins in 83% of the patients. Verification of diagnosis and evaluation of therapy was performed by phlebography, plethysmography and thermography. The results showed that heparin administered s.c. twice daily was as efficient as continuous i.v. infusion in preventing extension of the thrombus. In two patients the s.c. administration was stopped due to local haematomas at the injection sites. Retroperitoneal or intramuscular bleedings occurred in four patients, two in each group. Two major, non-fatal pulmonary emboli occurred, one in each group.

Measurement of fibrinopeptide A in the evaluation of heparin activity and fibrin formation during hemodialysis.

In order to monitor heparin activity during hemodialysis, were evaluated three commonly used methods; measurement of whole blood activated coagulation time (WBACT), whole blood thrombin time (WBTT) and heparin concentration in plasma, determined with a chromogenic substrate. Studies were performed on six regular dialysis patients during 4-hour dialysis sessions, employing three different heparin regimens; a single intravenous loading dose only, priming of the dialyzer with heparin followed by a heparin infusion and a pharmaco-kinetic model. Efficacy of heparinization was assessed by determination of fibrinopeptide A (FPA) which is a peptide split product of the fibrinogen molecule formed during thrombin-induced conversion to fibrin. There was a linear correlation (r = 0.95) between FPA-production in the dialyzer and the FPA content of the blood at the inlet to the dialyzer; the slope of the correlation line indicates that at least 65% of FPA formed in the dialyzer is disposed during passage through the patient. Considerably higher production of FPA was noted when the heparin concentration was below 0.5 IU/ml than at a higher level. This was a common finding at the end of a dialysis, regardless of regimen. No consumption of antithrombin (AT III) occurred during a dialysis with any of the heparin regimens. Good correlations were found between WBACT, WBTT and heparin concentration. Heparin activity during a dialysis may be monitored with any of these three methods with equal reliability. However, from a practical point of view, WBACT appears most attractive because of its simplicity. FPA generation, frequency of visible clots in the dialyzer and hemorrhagic manifestations were essentially the same for each of the heparin dose regimens. The simple administration of a single loading dose was as safe as the more complicated infusion technique.

The effects of three different heparin regimes on heparin concentrations in plasma and fibrin formation in dialyzers.

Anticoagulation effects were studied during a 4-hr hemodialysis in 6 patients using 3 different heparin regimens: I. Intravenous loading dose only; II. priming of the dialyzer and continuous infusion of heparin for 2 hr; III. intravenous loading dose and continuous infusion of heparin based on anticoagulation kinetics. In all regimens the difference of fibrinopeptide A (delta FPA) between the blood inlet and outlet of the dialyzers increased at the end of the dialyses, indicating increased fibrin formation. There was a good correlation between delta FPA and the fibrin deposition on the membranes measured with I-125-fibrinogen. delta FPA increased when heparin concentration in plasma was less than 0.5 IU/ml. The anticoagulation kinetic regimen offered no advantage over the single loading dose regimen with regard to the formation and deposition of fibrin in the dialyzers.