Person-centred care on the move - an interview study with programme directors in Swedish higher education.

BACKGROUND: There is an increasing trend towards person-centred care (PCC) worldwide, suggesting that PCC should be mastered by future health care professionals. This study aims to explore programme directors' views on facilitators and barriers to implementing PCC in four of the largest national study programmes in Sweden training future health care professionals. METHODS: A qualitative design was applied and interviews were conducted with 19 programme directors of Swedish national study programmes in medicine, nursing, occupational therapy and physiotherapy. The interviews were analysed using qualitative content analysis. Themes were sorted according to the Consolidated Framework for Implementation Research (CFIR) in an abductive approach. COREQ guidelines were applied. RESULTS: The overarching theme, as interpreted from the programme directors' experiences, was 'Person-centred care is on the move at different paces.' The theme relates to the domains identified by the CFIR as outer setting, innovation, inner setting and process. PCC was understood as something familiar but yet new, and the higher education institutions were in a state of understanding and adapting PCC to their own contexts. The movement in the outer setting consists of numerous stakeholders advocating for increased patient influence, which has stirred a movement in the inner setting where the higher educational institutions are trying to accommodate these new demands. Different meanings and values are ascribed to PCC, and the concept is thus also 'on the move', being adapted to traditions at each educational setting. CONCLUSION: Implementation of PCC in Swedish higher education is ongoing but fragmented and driven by individuals with a specific interest. There is uncertainty and ambiguity around the meaning and value of PCC and how to implement it. More knowledge is needed about the core of PCC as a subject for teaching and learning and also didactic strategies suitable to support students in becoming person-centred practitioners.

Is out-of-hours cholecystectomy for acute cholecystitis associated with complications?

BACKGROUND: Existing data on the safety of out-of-hours cholecystectomy are conflicting. The aim of this study was to investigate whether out-of-hours cholecystectomy for acute cholecystitis is associated with a higher risk for complications compared with surgery during office hours. METHODS: This was a population-based cohort study. The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) was used to investigate the association between out-of-hours cholecystectomy for acute cholecystitis and complications developing within 30 days. Data from patients who underwent cholecystectomy between 2006 and 2017 were collected. Out-of-hours surgery was defined as surgery commencing between 19.00 and 07.00 hours on weekdays, or any time at weekends (Friday 19.00 hours to Monday 07.00 hours). Multivariable logistic regression analysis was used to assess the risk of complications, with time of procedure as independent variable. The proportion of open procedures and proportion of procedures exceeding 120 min were also analysed. Adjustments were made for sex, age, ASA grade, time between admission and surgery, and hospital-specific features. RESULTS: Of 11 153 procedures included, complications occurred within 30 days in 1573 patients (14·1 per cent). The adjusted odds ratio (OR) for complications for out-of-hours versus office-hours surgery was 1·12 (95 per cent c.i. 0·99 to 1·28). The adjusted OR for procedures completed as open surgery was 1·39 (1·25 to 1·54), and that for operating time exceeding 120 min was 0·63 (0·58 to 0·69). CONCLUSION: Out-of-hours complications may relate to patient factors and the higher proportion of open procedures.

ANTECEDENTES: Los datos existentes sobre la seguridad de la colecistectomía fuera del horario laboral son discordantes. El objetivo de este estudio fue investigar si la colecistectomía para el tratamiento de la colecistitis aguda realizada fuera del horario laboral se asocia con un mayor riesgo de complicaciones en comparación con la cirugía efectuada durante el horario laboral. MÉTODOS: Se trata de un estudio de cohortes de base poblacional. Se utilizó el registro Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) para examinar la asociación entre la colecistectomía por colecistitis aguda realizada fuera del horario laboral y las complicaciones a los 30 días. Se recogieron los datos de los pacientes en los que se realizó una colecistectomía entre 2006 y 2017. Se definió como cirugía fuera del horario laboral aquella realizada entre las 19:00 y las 07:00 de lunes a viernes y en cualquier momento durante los fines de semana (de viernes 19:00 a lunes 07:00) Se realizó un análisis de regresión logística multivariable para evaluar el riesgo de complicaciones, considerando la hora de la cirugía como variable independiente. También se analizó el porcentaje de intervenciones por vía abierta y el de aquellas cuya duración excedió de los 120 minutos. Se realizaron ajustes por sexo, edad, puntuación ASA, días desde el ingreso hasta la cirugía y características específicas del hospital. RESULTADOS: Se produjeron 1.573 (14,1%) complicaciones en las 11.153 intervenciones incluidas. La razón de oportunidades, odds ratio (OR) ajustada para las complicaciones comparando la cirugía fuera del horario laboral con la cirugía dentro del horario laboral, fue de 1,12 (i.c. del 95% 0,99-1,28). La OR ajustada para los procedimientos realizado por vía abierta fue de 1,39 (1,25-1,54). La OR ajustada para el tiempo operatorio > 120 minutos fue de 0,63 (0,58-0,69). CONCLUSIÓN: Las complicaciones que suceden en la cirugía efectuada fuera del horario laboral es más probable que se deban a factores relacionados con el paciente que con la hora del día en que se practica la cirugía. Debe tenerse en cuenta que las intervenciones realizadas por vía abierta fuera del horario laboral tienen una mayor morbilidad.

Daily life consequences, cognitive impairment, and fatigue after transient ischemic attack.

OBJECTIVES: Studies suggest that fatigue and cognitive impairment may be present after transient ischemic attack (TIA), but little is known about consequences in daily life. The main aim was to longitudinally explore the presence of fatigue, cognitive impairment, and consequences in daily life including communication after clinically diagnosed TIA at 1 and 9 months after the event. MATERIAL AND METHODS: A consecutive sample of 46 patients (23 women, 69 ± 12.3 years) was assessed at discharge from hospital and at 1 and 9 months after TIA regarding cognition, mental fatigue, tiredness, and activities of daily life. This served as basis for an interview concerning experienced changes related to the TIA. RESULTS: Problems in daily life with probable association with the TIA were experienced by 37% (n = 45) of participants 9 months after the TIA event. Cognitive impairment was present in 40% (n = 44) after 1 month and 30% (n = 23) after 9 months. Mental fatigue was experienced by 26% (n = 42) after 1 month and 17% (n = 39) after 9 months. Communication problems were reported and increased from 7 to 14 participants between the two time points. CONCLUSIONS: A third of the TIA patients experienced problems in performance of complex activities in daily life and often communication problems within the first 9 months. Cognitive impairment and mental fatigue could be factors influencing performance in daily life and at work, but this needs to be verified in a larger sample. The risk of activity limitations indicates need for multiprofessional support and systematic routines for TIA follow-up.

Methods to evaluate perspectives of safety, independence, activity, and participation in older persons using welfare technology. A systematic review.

Purpose: To conduct a systematic review of existing methods to evaluate the individual aspects of welfare technology from the perspectives of independence, safety, activity, and participation. Furthermore, the study aimed to describe outcomes that have been the focus of previous research to evaluate individual aspects of welfare technology in older persons living in ordinary housing. Materials and methods: A systematic literature review in PubMed, CINAHL Plus, PsycINFO, Scopus, and Web of Science. Studies selected were those that explored the use of assistive and welfare technology devices from older persons' perspectives, and which considered the concepts of independence, safety, activity and participation, and quality of life. Results: A broad spectrum of instruments was applied in the studies. For independence, three questionnaires were used in the identified studies. For safety, one instrument was used in two versions. To study activity and participation as well as quality of life, several scales were used. Additionally, several studies included qualitative approaches for evaluation, such as interviews, or posed one or more questions regarding the effects of welfare technology. Conclusions: The integration of digital assistive and welfare technology should be based on the needs of older persons, and those needs must be assessed using reliable and relevant instruments. The heterogeneity of the target group, i.e., older persons, together with the fact that assessments must give consideration to identifying goals, obstacles, and risks as well as users' preferences, implies a person-centred approach.Implications for rehabilitationThe integration of digital assistive and welfare technology should be based on older persons' needs, and those needs must be assessed using reliable and relevant instruments.The heterogeneity of the target group, i.e. older persons, together with the fact that assessments must give consideration to identifying goals, obstacles and risks as well as users' preferences, implies a person-centred approach.The ideal would be one coherent model that explores the use of digital assistive and welfare technology from the individual, economic as well as organisational dimensions. This would cover the different needs and expectations of various stakeholders, including economic and organisational, but also the needs of the older person.

Conserved structures of mediator and RNA polymerase II holoenzyme.

Single particles of the mediator of transcriptional regulation (Mediator) and of RNA polymerase II holoenzyme were revealed by electron microscopy and image processing. Mediator alone appeared compact, but at high pH or in the presence of RNA polymerase II it displayed an extended conformation. Holoenzyme contained Mediator in a fully extended state, partially enveloping the globular polymerase, with points of apparent contact in the vicinity of the polymerase carboxyl-terminal domain and the DNA-binding channel. A similarity in appearance and conformational behavior of yeast and murine complexes indicates a conservation of Mediator structure among eukaryotes.

Directed evolution: the 'rational' basis for 'irrational' design.

The development of powerful genetic manipulation formats has revolutionized the creation of functional biological molecules. Recent advances in directed evolution demonstrate that multiple properties of proteins can be optimized simultaneously and rapidly. Improved proteins often contain multiple and dispersed substitutions that act synergistically to improve enzyme properties and function. The benefits of such multiple changes are often not predictable from a priori structural knowledge. Furthermore, alternative solutions to gaining functional change can be obtained.

Assessment of dosimetric impact of system specific geometric distortion in an MRI only based radiotherapy workflow for prostate.

Dosimetric errors in a magnetic resonance imaging (MRI) only radiotherapy workflow may be caused by system specific geometric distortion from MRI. The aim of this study was to evaluate the impact on planned dose distribution and delineated structures for prostate patients, originating from this distortion. A method was developed, in which computer tomography (CT) images were distorted using the MRI distortion field. The displacement map for an optimized MRI treatment planning sequence was measured using a dedicated phantom in a 3 T MRI system. To simulate the distortion aspects of a synthetic CT (electron density derived from MR images), the displacement map was applied to CT images, referred to as distorted CT images. A volumetric modulated arc prostate treatment plan was applied to the original CT and the distorted CT, creating a reference and a distorted CT dose distribution. By applying the inverse of the displacement map to the distorted CT dose distribution, a dose distribution in the same geometry as the original CT images was created. For 10 prostate cancer patients, the dose difference between the reference dose distribution and inverse distorted CT dose distribution was analyzed in isodose level bins. The mean magnitude of the geometric distortion was 1.97 mm for the radial distance of 200-250 mm from isocenter. The mean percentage dose differences for all isodose level bins, were ⩽0.02% and the radiotherapy structure mean volume deviations were <0.2%. The method developed can quantify the dosimetric effects of MRI system specific distortion in a prostate MRI only radiotherapy workflow, separated from dosimetric effects originating from synthetic CT generation. No clinically relevant dose difference or structure deformation was found when 3D distortion correction and high acquisition bandwidth was used. The method could be used for any MRI sequence together with any anatomy of interest.

Cytokine secretion in decidual mononuclear cells from term human pregnancy with or without labour: ELISPOT detection of IFN-gamma, IL-4, IL-10, TGF-beta and TNF-alpha.

Cytokines are believed to be important in maintaining pregnancy and in the process of labour induction in humans. The aim of this study was to investigate the secretion of the cytokines interferon-gamma (IFN-gamma), interleukin-4 (IL-4), IL-10, transforming growth factor-beta (TGF-beta) and tumour necrosis factor-alpha (TNF-alpha) in decidual tissue with or without labour. Decidual tissue was collected from 32 healthy women undergoing elective caesarean sections before the onset of labour (n=17) or after normal vaginal delivery (n=15). Mononuclear cells were analysed for cytokine secretion with ELISPOT. To validate the widely used method of tissue collected at caesarean sections and after vaginal deliveries as a representative of before and after labour, respectively, placenta biopsies were collected from 12 healthy women to study the expression of the prostaglandin pathway enzymes cyclooxygenase-2 (COX-2) and microsomal prostaglandin E(2) synthase (mPGES). Decidual mononuclear cells from term human pregnancy spontaneously secrete IFN-gamma, IL-4, IL-10, TGF-beta and TNF-alpha. No difference was seen in cytokine secretion with or without labour, indicating that decidual leukocytes are not the main cell population responsible for plausible cytokine regulation in the process of termination of pregnancy. Placental tissues obtained after vaginal delivery showed a higher mRNA expression of the prostaglandin regulating molecules COX-2 and mPGES than tissues from caesarean sections before the onset of labour, validating that the model can be used as a representative of the state before and after labour.

Production of large amounts of recombinant interleukins by cDNA transfected mouse myeloma cells cultured in dialysis tubing.

Studies of interleukin function often require large quantities of these highly expensive substances. The available interleukins are generally recombinant proteins produced in bacteria or yeast and, less commonly, interleukins produced by mammalian cells, which provide appropriate glycosylation and other post-translational modifications. Due to differences in biosynthesis, difficulties in production and purification the quality of the interleukin preparations may vary. We have taken advantage of the recently developed constitutively interleukin-secreting mouse myeloma cell lines and the dialysis tubing culture technique, which permit cells to be grown at high densities, in order to establish a method for the production of large amounts of recombinant murine IL-2 and IL-4. We show that these interleukins can be produced at low cost and in concentrations 20-30-fold higher than in conventional culture flasks. A single dialysis tubing culture will produce more than 10(6) U of interleukin which may be compared with the available commercial preparations containing between 10- and a 100-fold less per vial. The IL-2 and IL-4 produced in this manner are biologically active molecules as demonstrated by the strong proliferative response of clonal T cells and the isotype-switching effect in LPS-stimulated splenic B cell cultures. The dialysis tubing culture technique is a simple and highly cost-effective means of generating large quantities of biologically active interleukins and is especially suitable for research laboratories interested in functional studies of these proteins.

Characterisation of particle properties and compaction behaviour of hydroxypropyl methylcellulose with different degrees of methoxy/hydroxypropyl substitution.

The particle characteristics and compaction behaviour of hydroxypropyl methylcellulose (HPMC) powders from two different suppliers were studied regarding effects of methoxy/hydroxypropyl substitution. Samples included Methocel K4M (low substitution ratio), E4M (medium) and F4M (high) and the corresponding substitution ratios from Metolose: 90 SH 4000, 60 SH 4000, and 65 SH 4000. Characterisation of the particle properties and compaction behaviour of the pure polymers suggested that reported differences in drug release behaviour of Methocel E4M compared with the other two powders may be related to the lower powder surface area, differing particle morphology and lower fragmentation propensity during compaction. In addition, compacts of Methocel E4M were weaker when tested in both axial and radial directions and had different porosity and elastic recovery properties. There were no differences between the polymers in degree of disorder, as evaluated by solid-state nuclear magnetic resonance spectroscopy. The different behaviour of Methocel E4M could, however, be related to the overall higher total degree of substitution of this polymer and in particular the high content of methoxy groups compared to the other polymers. The methoxy substituent is hydrophobic and may, when present in sufficiently high concentrations, change the particulate and mechanical properties of the powder, thus potentially affecting the compactability. The high content of methoxy groups might also decrease the development of inter- and intraparticulate hydrogen bonds during compaction, and suppress the actions of the hydrophilic hydroxypropyl groups, both of which could affect drug release.

The influence of water content and drug solubility on the formulation of pellets by extrusion and spheronisation.

The influence of drug solubility in the range 14.3-1000 gl-1 on the formation of pellets by extrusion and spheronisation has been investigated by evaluating the performance of a series of model drugs mixed with an equal part by weight of microcrystalline cellulose. The optimum formulation in terms of pellet roundness and the maximum quantity within a limited size range was established by preparing samples with a range of water levels. The range of water levels over which pellets could be formed was found to be dependent on the model drug and its particle size. In general the force necessary to extrude the wet mass through the ram extruder was found to decrease as the quantity of water added increased. The optimum water level required to form the best quality pellets was found to decrease as a linear function of the natural logarithm of the water solubility of the drug. If allowance is made for the loss of solid by dissolution of the drug, there is an increase in the apparent water content necessary to form good spheres above a critical solubility between 350 and 400 gl-1.

Reliability and responsiveness of three different pain assessments.

The visual analogue scale (VAS) and ordered categorical scales, i.e. numeric rating scales (NRS), are commonly used in the assessment of pain. However, these scales are bounded by fixed endpoints and thus the range of measurement is limited. The disparity in repeated assessments of perceived pain intensity with the VAS, NRS, and electrical stimulation applied as a matching stimulus was studied in 69 patients (48 women and 21 men, 19-72 years) with chronic nociceptive or neurogenic pain. Responsiveness with transcutaneous electrical nerve stimulation (TENS) using the same measurement procedures was evaluated in the same patients. Comparison of results from the three pain assessments showed that the painmatcher is at least as reliable and responsive as VAS and NRS. None of the three measurements showed evidence for systematic disagreement and had only significant random individual disagreement. They also showed evidence for responsiveness.

Effects of normobaric hypoxic confinement on visual and motor performance.

INTRODUCTION: The use of reduced oxygen levels has been suggested for fire prevention in closed spaces, such as submarines. However, if humans are to work and live in environments with reduced oxygen levels, the effect of hypoxia on human performance must be further assessed. METHODS: In 3, 11- to 14-d confinements a total of 22 subjects were exposed to different levels of normobaric hypoxia (13, 14, and 15 kPa O2), for up to 10 d, with intervening periods of normoxia. In each experiment eight subjects were divided into two teams, working in 6-h shifts around the clock. Subjects performed tests of spatial orientation, visual reaction time, parallel processing and motor skills. Performance tests and questionnaires were administered once or twice in every 24-h period. RESULTS: All of the subjects appeared to tolerate the acute reduction in oxygen partial pressure well. In many of the tests performance improved with time as a result of learning, despite reductions in the oxygen level. No reduction in performance or decrease in rate of learning was observed at any of the oxygen levels tested. CONCLUSIONS: Oxygen levels down to 14 kPa appear not to impair visual and motor performance during rest.

Cost effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective.

OBJECTIVE: To assess the potential effects of primary prevention with anticoagulants or aspirin in atrial fibrillation on Swedish population. DESIGN: Analysis of cost effectiveness based on the following assumptions: about 83,000 people have atrial fibrillation in Sweden, of whom 22,000 would be potential candidates for treatment with anticoagulants and 55,000 for aspirin treatment; the annual 5% stroke rate is reduced by 64% (with anticoagulants) and 25% (with aspirin); incidence of intracranial haemorrhage of 0.3%, 1.3%, or 2.0% per year; direct and indirect costs of a stroke of Kr180,000 and Kr90,000; estimated annual cost of treatment is Kr5030 for anticoagulants and Kr100 for aspirin. SETTING: Total Swedish population. MAIN OUTCOME MEASURES: Direct and indirect costs of stroke saved, number of strokes prevented, and cost of preventive treatment. RESULTS: Depending on the rate of haemorrhagic complications 34 to 83 patients would need to be treated annually with anticoagulants to prevent one stroke; 83 patients would need to be treated with aspirin. Giving anticoagulant treatment only would reduce costs by Kr60 million if the incidence of intracranial haemorrhage were 0.3% but would imply a net expense if the complication rate exceeded 1.3%. The total savings from giving anticoagulant (22,000 patients) and aspirin (55,000 patients) treatment would be Kr175 million per year corresponding to 2 million pounds per million inhabitants each year. CONCLUSIONS: Treatment with anticoagulants and, if contraindications exist, with aspirin is cost effective provided that the risk of serious haemorrhage complications due to anticoagulants is kept low.

Occurrence of methicillin-resistant Staphylococci in surgically treated dogs and the environment in a Swedish animal hospital.

OBJECTIVES: To investigate whether hospitalised dogs treated surgically may become culture positive for methicillin-resistant Staphylococcus pseudintermedius or methicillin-resistant Staphylococcus aureus. METHODS: Surgically treated dogs (n=45) were sampled for methicillin-resistant Staphylococcus pseudintermedius or methicillin-resistant Staphylococcus aureus on admission, before and after surgery and at the time of removal of surgical stitches. The hospital environment (n=57), including healthy dogs in the veterinary hospital environment (n=34), were sampled for methicillin-resistant Staphylococcus pseudintermedius or methicillin-resistant Staphylococcus aureus. Genetic variations among methicillin-resistant Staphylococcus pseudintermedius or methicillin-resistant Staphylococcus aureus isolates were identified through detection of restriction fragment polymorphisms. RESULTS: No dogs developed a wound infection due to methicillin-resistant Staphylococcus pseudintermedius or methicillin-resistant Staphylococcus aureus. However, there was a significant increase in the number of dogs carrying methicillin-resistant Staphylococcus pseudintermedius after hospitalisation compared to admission (P<0·001). No methicillin-resistant Staphylococcus aureus was isolated from dogs, but was present in the environment. Methicillin-resistant Staphylococcus pseudintermedius isolates were recovered from environmental surfaces and hospitalised animals, but not from healthy dogs. Methicillin-resistant Staphylococcus pseudintermedius isolates representing nine different restriction endonuclease digestion patterns were found, with two of these occurring in both the environment and on dogs. CLINICAL SIGNIFICANCE: Dogs may contract methicillin-resistant Staphylococcus pseudintermedius in association with surgery and hospitalisation. Resistant bacteria may be transmitted between dogs, staff and the environment. Dogs colonised with methicillin-resistant Staphylococcus pseudintermedius may be a source for hospital- and community-acquired infections.

Sequence analysis of human rhinovirus aspirated from the nasopharynx of patients with relapsing-remitting MS.

BACKGROUND: Upper respiratory infections were reported to trigger multiple sclerosis relapses. A relationship between picornavirus infections and MS relapses was recently reported. OBJECTIVE: To evaluate whether human rhinovirus is associated with multiple sclerosis relapses and whether any particular strain is predominant. METHOD: Nasopharyngeal fluid was aspirated from 36 multiple sclerosis patients at pre-defined critical time points. Reverse-transcriptase-PCR was performed to detect human rhinovirus-RNA. Positive amplicons were sequenced. RESULTS: We found that rhinovirus RNA was present in 17/40 (43%) of specimens obtained at the onset of a URTI in 19 patients, in 1/21 specimens during convalescence after URTI in 14 patients, in 0/6 specimens obtained in 5 patients on average a week after the onset of an "at risk" relapse, occurring within a window in time from one week before to three weeks after an infection, and in 0/17 specimens obtained after the onset of a "not at risk" relapse not associated with any infection in 12 patients. Fifteen specimens from healthy control persons not associated with URTI were negative. The frequency of HRV presence in URTI was similar to that reported for community infections. Eight amplicons from patients represented 5 different HRV strains. CONCLUSION: We were unable to reproduce previous findings of association between HRV infections and multiple sclerosis relapses. HRV was not present in nasopharyngeal aspirates obtained during "at risk" or "not at risk" relapses. Sequencing of HRV obtained from patients during URTI did not reveal any strain with predominance in multiple sclerosis.

Isolation of genes encoding tRNA binding proteins by probing an expression library with unmodified tRNA.

A rapid method for isolating Escherichia coli genes encoding proteins which bind unmodified, but not modified, tRNA is described. The method is generally applicable, and can be used to clone many RNA binding proteins where a structured RNA ligand is known.

The prevalence of people with intellectual disability admitted to general hospital psychiatric units: level of handicap, psychiatric diagnoses and care utilization.

Previous studies have stated that people with intellectual disability (ID) are more often afflicted by psychiatric disorders than the general population. In spite of the high prevalence of psychiatric disorders among people with ID, it is not known how many actually receive psychiatric in-patient care and treatment by the mental health services. In the present study, the number of people with mild and severe ID admitted to in-patient psychiatric care were compared with corresponding figures in the general population in Sweden. The results show a low frequency of psychiatric care utilization among people with ID and coexisting psychiatric disorders in comparison to the proportion of psychiatric care utilization among people with psychiatric disorders in the general population. The results are discussed in terms of how the level of ID might influence referral or diagnoses, the length of admissions, and the support provided within the special services to people with ID and psychiatric disorders.