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.

Extra-articular manifestations in a community-based sample of patients with rheumatoid arthritis: incidence and relationship to treatment with TNF inhibitors

OBJECTIVES

To determine the incidence of severe extra-articular rheumatoid arthritis (ExRA) in a community-based cohort of RA patients, and to evaluate whether treatment with tumour necrosis factor (TNF) inhibitors has any effect on the risk of ExRA.

METHODS

In a review of clinical records from 1 July 1997 to 31 December 2004, severe ExRA manifestations were classified according to predefined criteria. Patients were censored at the development of ExRA, death, emigration, or 31 December 2004. Exposure to anti-TNF treatment has continuously and independently been recorded as part of a regional follow-up system.

RESULTS

During treatment with TNF inhibitors, there were two patients with new onset of ExRA in 408 person-years at risk (pyr) [0.49/100 pyr, 95% confidence interval (CI) 0.06-1.77]. Among those without anti-TNF treatment there were 63 patients with ExRA in 5425 pyr (1.16/100 pyr, 95% CI 0.89-1.49). The relative risk comparing those treated to those not treated with TNF inhibitors was 0.42 (95% CI 0.10-1.73).

CONCLUSION

Our data show a lower incidence of ExRA in patients treated with TNF inhibitors but further studies with a larger sample size are needed for a more accurate estimate of the size of the effect.

Economic evaluation of nursing practices: a review of literature

BACKGROUND

The importance of cost-effectiveness of nursing practices and its influence on prioritizations has been discussed in literature. It is, however, unclear to what extent health economic analysis has been used in the area of nursing.

AIM

The aim of this paper was to investigate how studies of nursing practices apply economic evaluations.

METHODS

A literature review was conducted that included studies through August 2007. The search was performed using Medline, CINAHL, PsycINFO, Econlit, DARE, HTA, NHS EED, Cochrane reviews and clinical trials with a search term connected to nursing and health economics. Protocols were used in the screening procedure and the result is reported in a descriptive form.

RESULTS

The search identified 115 studies published between 1984 and August 2007. Studies were found in the following nursing practices: provision of support and treatment (n = 17); assessing suffering/well-being (n = 1); preventing or treating ill health (n = 53); and organization of individual care (n = 44). In 22% of all studies, the authors explicitly presented the health economic method used. In 25% of all studies, the perspective of the economic analysis was explicitly stated and a large variability in cost was considered in the analysis. In 82 studies, the authors reported cost-effective intervention.

CONCLUSIONS

Although economic evaluation of nursing practice has increased, it is still a rather small area. According to the items elucidated in this study, further methodological improvement is needed to evaluate the economics of nursing.

Development of speech, feeding, eating, and facial expression in Möbius sequence

OBJECTIVE

Möbius sequence is a rare congenital disorder with the primary diagnostic criteria of congenital facial and abducens nerve palsy. Involvement from other cranial nerves is common. Orofacial anomalies and limb malformations may be associated with the disorder. Mental retardation and autism have been reported in some. The aim of this study was to describe orofacial dysfunction observed in a prospective, multidisciplinary study of individuals with Möbius sequence.

METHODS

Twenty-five patients with Möbius sequence, aged 2 months to 54 years, participated in the study. Clinical observations by different medical specialists were collected in an established database. Dentists and a speech pathologist made the orofacial examination. The parents or the patient described orofacial function and dysfunction through interviews and a questionnaire.

RESULTS

Bilateral facial palsy was observed in 16 patients, unilateral palsy in 9. Observed orofacial anomalies were tongue dysfunction (16), micrognatia (8), microglossia (7), cleft palate (4), and cleft lip (1). Seventeen had speech problems, 16 reported feeding difficulties in infancy, 14 eating problems, and 8 drooling.

CONCLUSIONS

Orofacial problems are common in Möbius sequence and have a significant impact on the quality of life for the patient and for the whole family. Early intervention by a speech pathologist and a paediatric dentist should be undertaken to improve orofacial function and symptoms. Plastic surgery, oral motor training, facial massage, speech therapy, and orthodontic treatment are some of the therapy methods that can be considered.

Evaluation of the QALY model for analysis of cost-effectiveness of eating training after stroke

New methods developed and insights gained in research are of increasing significance in health care and the question is which services and methods are to be implemented. If eating training after stroke is to be implemented it must be given priority in relation to other measures. Otherwise there is a risk that patients with eating difficulties after stroke will be fed by personnel or permanently receive nourishment via tube. This may lead to expensive measures or costs for the tube feeding as well as costs for the personnel needed for feeding, and patients' well-being will be reduced if they do not have the opportunity to eat as independently as possible. Economic analyses should not guide the priorities to be made, but can be one of several bases for resource allocation. The estimation of cost-effectiveness must, however, be made by means of a method which in its ethical foundation is in line with nursing and the Swedish Government Bill for guiding priorities in health care. The aim of this paper is to discuss the ethical foundation of nursing care and the ethical principles proposed by the Swedish Government Bill for guiding priorities in health care and the model of Quality Adjusted Life Years (QALYs) related to eating training after stroke. The findings showed that there was a considerable difference in the ways health and health maximization were discussed in the QALY model and in specific nursing care. There are two aspects underpinning the QALY model that are not in line with either the ethical foundations of nursing or the principles proposed by the Swedish Government Bill for guiding priorities in health care. However, a new method called Equity Adjusted Life Years (EQALYs) can be a tool for evaluation in specific nursing care. Cost per EQALY is based on a compromise between initial severity of disease and treatment effect that is very close to the distribution rule applied in specific nursing care. In conclusion it is obvious that cost per EQALY, a balance between health maximization and severity of disease and treatment effects, can be a tool for the evaluation of eating training after stroke.

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND

The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed.

METHODS

A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards.

RESULTS

The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients.

CONCLUSIONS

A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

How people with stroke and healthy older people experience the eating process

The aim of this study was to describe the process of eating, experiences of eating and oral functions. Participants consisted of 30 people with first stroke and localization of the damage verified by computer topography (CT), and 15 healthy older people. All were observed during test-meals, interviewed about eating, and oral functions were tested. The results demonstrated that most (21) people with stroke had some difficulties in eating and expressed feelings of fear and shame about eating and changed physical and social appearance, mainly related to difficulties in preparing and transporting food to the mouth as well as swallowing deficits.

First and Second Branchial Arch Syndrome: Aspects on the Embryogenesis, Elucidations, and Rehabilitation Using the Osseointegration Concept

BACKGROUND

The osseointegration concept has dramatically changed the possibility of rehabilitating patients with craniofacial defects due to branchial arch syndromes.

PURPOSE

This article describes some problems related to the investigative routines and rehabilitation of individuals with malformations of the first and second branchial arches of the craniofacial region. Animal model systems have increased the knowledge of basic embryonic processes that can explain the extent of the malformations. Though most clinical first and second branchial arch syndromes are likely to be caused by sporadic mutations, inherited syndromes occur and also teratogenically induced syndromes are known. Prenatal diagnosis ruling out heredity and exogenous influence seems possible in the future. The possibility of preventing and alleviating fulminant syndromes prenatally also could be conceivable in the future.

PATIENTS AND METHODS

The rehabilitation process starts early after birth and should involve a team of specialists including clinical geneticists, pediatricians, audiologists, plastic surgeons, maxillofacial surgeons, otosurgeons, anaplastologists, speech pathologists, pedodontists, and orthodontists. With the development of the osseointegration concept in which craniofacial prostheses and hearing aids can be adapted on implants anchored in the craniofacial skeleton, a new field in the rehabilitation of these malformations has opened.

RESULTS

Important aspects in the use of the osseointegration concept include determination of the lowest age for implant surgery, accessibility of adequate bone for implants, the growth of the craniofacial skeleton during childhood, and the possibility for the patient and his or her parents to care for the skin penetration. Adverse tissue reactions, durability of craniofacial prostheses, and the possibility of unknown adverse reactions to metal implants in the body over a long time are other aspects of concern.

CONCLUSIONS

Patients with branchial arch syndromes benefit from a well-planned multidisciplinary rehabilitation process in which osseointegrated bone-anchored hearing aids and bone-anchored ear prostheses can be useful tools.

Clinical appearance of spontaneous and induced first and second branchial arch syndromes

The clinical appearance was investigated of 29 patients with mandibulofacial dysostosis, 26 with hemifacial microsomia, and seven with thalidomide-induced malformations affecting derivatives of the first and second branchial arches. Malformations of the external ear, ear canal, middle ear, zygoma, maxilla, mandible, and lower eye lid were prominent features of the syndromes. Facial nerve and 6th cranial nerve paralysis as well as anophthalmia or microphthalmia were seen only in patients with hemifacial microsomia and in the thalidomide-induced syndrome. We compared the clinical results with those in an animal model in which an induced first and second branchial arch syndrome depends on disturbed migration of neural crest cell during early embryogenesis. The critical time for a similar process in humans would be between the 20th and 29th days of pregnancy.

Etretinate-induced malformation of the first two branchial arches: differential staining and microdissection study of embryonic cartilage

Malformations of the cranial base, temporal bone and middle ear were induced in the offspring of Sprague-Dawley rats by a single intraperitoneal injection of 10-30 mg/kg etretinate (Tigasone) at days 8.5-10.5 of gestation. By differential staining of the embryonic craniofacial cartilage and bone, and microdissection of the otomandibular complex, the induced malformations were studied specifically. Defective formations of Meckel's cartilage and the cartilaginous skull base were found to be prominent features of the malformation. The malformation included defective middle-ear ossicles; especially the malleus and incus were fused with a shorter than normal long process and manubrium. In conjunction with the distal part of Meckel's cartilage, mandibular micrognathia was observed. All of the malformed tissues are derivatives of the first and second branchial arches. The teratogenically induced defects in the rat embryos show some similarities to the clinical syndromes of the first and second branchial arches in man.

Effects of vitamin B6 on beta-aminoproprionitrile-induced palatal cleft formation in the rat

OBJECTIVE

This study was conducted to evaluate the effects of beta-aminoproprionitrile and vitamin B6 on palatal clefting.

METHOD

In four groups of pregnant Sprague-Dawley rats, beta-aminoproprionitrile (BAPN; 600 mg/kg b.w.) was given by gavage on embryonal day 15, 7 hours to induce palatal clefts. Vitamin B6 (10 mg/kg b.w., IM) was given twice on embryonal day 14, 7 hours and on day 15, 7 hours. The possibility that the food's content of vitamin B6 affected the results was also tested. Palatal cleft formation was divided into four different grades, ranging from no cleft formation to total cleft formation.

RESULTS/CONCLUSION

It was found that BAPN induces cleft palate in rat fetuses and that this defect can be prevented both in number and severity by administration of vitamin B6 before and simultaneously with BAPN.

Outcomes of individualized interventions in patients with severe eating difficulties

The aim of this case study is to describe the outcomes of individualized interventions for patients with severe eating difficulties. The participants were 15 patients who had severe eating difficulties following a stroke or brain tumor and were receiving oral feeding or tube feeding. Interventions focused on training functions needed for eating, activities in eating, and discussions with the patient. Improvements were especially noted in eating activities, and some improvements were noted in oral movements and nutritional status. Before the interventions, none of the patients ate regular food; afterward, six did, and in four patients, the feeding tube was removed. The patients said eating was easier, and they could eat in a safe way. Furthermore, they appreciated the attention to their experience during meals. Although the impairments were not always alleviated, the patients found means to cope with their eating difficulties.

Teratological studies on craniofacial malformations

Craniofacial malformations cause great human suffering. The purpose of the experimental studies was to investigate teratogenically induced craniofacial malformations in the rat, and to study if vitamin B6 could prevent the teratogenically induced malformations in the rat. The aim of the clinical investigation was to compare mandibulofacial dysostosis (MFD) with hemifacial microsomia (HFM) and thalidomide-induced malformations restricted to the first and second branchial arches. In the experimental studies we used two different teratogenic agents, etretinate and BAPN (beta-aminoproprionitrile). Vitamin B6 was administered one day prior to and simultaneously with the teratogenic agent. The induced malformations were observed by direct microscopy, histology, differential staining, microdissection and enzyme histochemistry. Knowledge of isoenzymic differentiation was obtained by isoelectric focusing and polyacrylamide gel electrophoresis. The clinical features of 29 patients with MFD, 26 with HFM and seven with thalidomide-induced malformations were investigated. The patients underwent clinical investigations, radiography, tomography, computed tomography, surgical exploration and audiograms. The etretinate-induced syndrome in the rat shows similarities to first and second branchial arch syndromes in man. Defective formation of Meckel's cartilage and the cartilaginous skull base, the zygoma and the middle ear ossicles were prominent features of the observed malformations. The induced malformations were accompanied by increased staining for alkaline phosphatase (APase) in the skull and skull base cartilages and Meckel's cartilage. BAPN induced cleft palate in 95% of the cases and the teratogenically induced cleft palate was accompanied by a pathological differentiation pattern that could be traced by determination of isoenzymes in the palatal shelves as well as in amniotic fluid. Vitamin B6 could prevent the teratogenic malformations induced by etretinate and BAPN in the rat. Comparing MFD, HFM and thalidomide-induced malformations, all syndromes included patients with external, middle and inner ear malformations. Cranial nerve palsy/paresis was only seen in HFM and thalidomide-induced malformations. A relationship between disturbed neural crest cell migration and defects of the first and second branchial arches seems possible.

Prevention of etretinate-induced craniofacial malformations by vitamin B6 in the rat

The preventive effect of vitamin B6 on etretinate-induced malformations in pregnant Sprague-Dawley rats was studied. The etretinate-induced malformation was produced by intraperitoneal administration of 10 mg/kg etretinate at embryonal day 8.5. Vitamin B6 was administered as intramuscular injections at embryonal day 7.5 and 8.5. Vitamin B6 reduced the number and severity of facial clefts, micrognatia, meningocele, microtia and blood vessel anomalies. It is suggested that vitamin B6 induces suppressive effects on etretinate-induced teratogenesis when administered before or at the same time as the teratogen.

Eating despite severe difficulties: assessment of poststroke eating

A programme for the assessment and nursing diagnoses of eating difficulties among stroke patients was tested. The patients' experiences regarding eating were expressed in interviews and dialogues. Eating was observed during both a test meal and regular meals. The assessments included the prerequisites for eating as well as oral, pharyngeal and oesophageal functions. General and specific nursing diagnoses as well as life consequences (handicap) were established, based on assessment of disabilities and impairments, and interviewing the patients and their families, respectively. The general nursing diagnoses were formulated on admission after the test meal and these were reformulated to form specific nursing diagnoses after assessments of the functions. The programme presented proved to be useful in clinical practice. It is emphasized that many assessments must be co-ordinated for each individual.

Altered Growth and Wood Characteristics in Transgenic Hybrid Aspen Expressing Agrobacterium tumefaciens T-DNA Indoleacetic Acid-Biosynthetic Genes

A key regulator of cambial growth is the plant hormone indoleacetic acid (IAA). Here we report on altered wood characteristics and growth patterns in transgenic hybrid aspen (Populus tremula L. x Populus tremuloides Michx.) expressing Agrobacterium tumefaciens T-DNA IAA-biosynthetic iaaM and iaaH genes. Eighteen lines simultaneously expressing both genes were regenerated. Of these, four lines, verified to be transgenic by northern blot analysis, were selected and raised under controlled growth conditions. All four lines were affected in their growth patterns, including alterations in height and stem diameter growth, internode elongation, leaf enlargement, and degree of apical dominance. Two transgenic lines, showing the most distinct phenotypic deviation from the wild type, were characterized in more detail for free and conjugated IAA levels and for wood characteristics. Both lines showed an altered IAA balance, particularly in mature leaves and roots where IAA levels were elevated. They also exhibited changes in wood anatomy, most notably a reduction in vessel size, an increase in vessel density, and changes in ray development. Thus, the recent development of techniques for gene transfer to forest trees enabled us to investigate the influence of an altered IAA balance on xylem development in an intact experimental system. In addition, the results demonstrate the possibility of manipulating wood properties in a forest tree through controlled changes of IAA concentration and distribution.

Diagnosis of induced cleft palate in rats from defective patterns of differentiation of isoenzymes

Cleft palate was induced in 420 embryos of Sprague-Dawley rats with a single oral dose of 600 mg/kg beta-aminoproprionitrile (BAPN) on embryonal day 15, 7 hours. The cleft palate was accompanied by a pathological differentiation pattern of various isoenzymes in palatal shelves. These isoenzymes could be detected in amniotic fluid from the 16th to the 20th days of pregnancy when they also had a pathological differentiation pattern. We conclude that teratogenically induced cleft palate in rats is accompanied by a pathological differentiation pattern that can be traced by determination of isoenzymes in the palatal shelves as well as in amniotic fluid.

Enzyme histochemical analysis of craniofacial malformations induced by retinoids

Craniofacial malformations were induced in 256 embryos from 32 pregnant rats by a single intraperitoneal injection of 10 mg/kg etretinate at 8.5 days gestation. The litters developed several malformations including microtia, low set and dorsally placed outer ears, defective middle ear ossicles, short cochleas, defectively differentiated Meckel's cartilages, micrognathia, rudimentary malar bones, lateral facial clefts, fistulas, and skin tags, all of which tissues are derivatives of the first and second branchial arches. The teratogenically induced syndrome shows similarities to the mandibulofacial dysostosis syndrome in man. The defects were accompanied by a change in the histochemical differentiation and location of various enzymes in the craniofacial tissues.