Patient perceived quality of cirrhosis care- adjunctive nurse-based care versus standard medical care: a pragmatic multicentre randomised controlled study

BACKGROUND

Cirrhosis treatment implies prevention and alleviation of serious disease events. Healthcare providers may, however, fail to meet patients' expectations of collaboration and specific needs of information and support. Individualised nursing care could meet patients' needs. The aim was thus to measure patient-perceived quality of care after adjunctive registered nurse-based intervention Quality Liver Nursing Care Model (QLiNCaM) compared with standard medical care.

METHODS

This pragmatic multicentre study consecutively randomised patients to either adjunctive registered nurse-based care, or standard medical care for 24 months (ClinicalTrials.gov NCT02957253). Patients were allocated to either group at an equal ratio, at six Swedish outpatient clinics during 2016-2022. Using the questionnaire 'Quality of care from the patient's perspective', patients rated their perceived lack of quality for the adjunctive registered nurse-based intervention compared with the control group at 12 and 24 months, respectively.

RESULTS

In total, 167 patients were recruited. Seven out of 22 items in the questionnaire supported the finding that 'lacking quality' decreased with adjunctive registered nurse-based care (p < 0.05) at 12 months follow-up; however, these differences could not be established at 24 months.

CONCLUSION

Additional structured registered nurse-based visits in the cirrhosis outpatient team provided support for improved patient-perceived quality of care during the first 12 months. Registered nurses increase patient involvement and present easy access to cirrhosis outpatient care. Patients express appreciation for personalised information. This study reinforces registered nurses' role in the outpatient cirrhosis team, optimising patient care in compensated and decompensated cirrhosis.

TRIAL REGISTRATION

Registered at Clinical Trials 18th of October 2016, [ https://www.

CLINICALTRIALS

gov ], registration number: NCT02957253.

Feeling safe or falling through the cracks-Patients' experiences of healthcare in cirrhosis illness: A qualitative study

INTRODUCTION

Patients with cirrhosis have a long-lasting relationship with medical personnel. Hierarchy in the healthcare contacts and feeling stigmatised may affect the patient's interactions with these care providers. Despite healthcare professionals' awareness of patients' increased self-care needs, patients report getting insufficient information and support. The patients' expectations and experiences of interacting with healthcare professionals in cirrhosis care is hence a research area that needs further investigation.

PURPOSE

To capture patients' descriptions of healthcare experiences in relation to cirrhosis illness.

MATERIAL AND METHODS

Data comprise semi-structured interviews (N = 18) and open-ended questionnaire responses (N = 86) of patients with cirrhosis. Braun and Clarke's thematic analysis process was used, including both semantic and inductive elements. The study is reported following the COREQ guidelines.

FINDINGS

The analysis resulted in two themes: 1) Struggle to be in a dialogue and 2) Being helped or harmed. Six sub-themes were identified concerning aspects of experiences within each theme during the analysis. These sub-themes included: 'getting information', 'being involved', 'being perceived as a person', 'enduring care', 'feeling lost in the healthcare organisation', and 'not being taken care of'.

CONCLUSIONS

Patients with cirrhosis express concerns regarding where to turn in the continuum of cirrhosis care. They emphasise the importance of being involved in the dialogue with the healthcare professional, to be perceived as a person with a unique need to be informed. The healthcare organisation and continuity of care are either viewed as confusing or as helping to shape a safe and trustful contact, which was an important difference in feeling helped or harmed. Hence, patients wished for improved collaboration with healthcare professionals and to receive increased information about their disease. Person-centred communication in nurse-led clinics may increase patient satisfaction and prevent patients from falling through the cracks.

One for all or all for one? An integrative review of research on frequent callers

Objective

Telephone health services is an increasing and integral part of health care in several countries. Callers who call repeatedly, in the current study "frequent callers" are present in all kinds of healthcare services, often constitute a considerable proportion of the total amount of calls and are complicated to help. The aim was to provide a comprehensive overview of research on frequent callers at a variety of telephone health services.

Methods

An integrative literature review. Literature was searched for the period 2011-2020 in CINAHL Plus, MEDLINE, APA PsycArticles, APA PsycInfo, and PubMed, and resulted in the inclusion of 20 articles.

Results

Studies on frequent callers (FCs) were found in the context of emergency medical services, telephone helplines, primary healthcare, and specialist medicine clinics. Frequent calling was associated with psychiatric comorbidity, and the reasons for calling were often multifaceted.

Conclusion

The strategies suggested for handling calls involved an individual approach, which could be enabled through multidisciplinary work.

Innovation

The main findings indicate a need for a systematic approach and guidelines to enable optimal help for FCs. Cooperation among healthcare instances seems to contribute to a more individual care for FCs.

Montelukast and Nightmares: Further Characterisation Using Data from VigiBase

INTRODUCTION

Montelukast is a medicine indicated for use in asthma. Psychiatric disorders including nightmares have not been described in clinical trials but during recent years have been included in the product information as having been reported post-marketing, without further description of the events. Previous descriptions in the scientific literature were based on limited numbers of reports or lacked detailed case information.

OBJECTIVE

The study aim was to further characterise post-marketing adverse drug reactions for nightmares, suspected to be induced by montelukast, to facilitate safer use of the medicine by providing additional information to patients and healthcare professionals.

METHODS

We clinically reviewed reports of nightmares with montelukast present in VigiBase, World Health Organization's global database of suspected adverse reactions to medicinal products, developed and maintained by the Uppsala Monitoring Centre, until 3 May, 2020.

RESULTS

There were 1118 reports of nightmares with montelukast in VigiBase, which provided valuable descriptions of the nightmares as well as information about the impact on the daily lives, with many cases describing a severe impact of the nightmares. About half of the reports were classified as serious. Two thirds concerned children, with the largest age group represented being children aged 5-10 years. In most cases, the nightmares disappeared upon discontinuation of the drug but for some patients it took a long time until the nightmares ceased.

CONCLUSIONS

The nature and potential severity of this adverse drug reaction, as described in these reports, present important knowledge for patients and healthcare providers that could help reduce drug-induced harm. This study highlights the value of post-marketing reports for further characterisation of known adverse drug reactions. The benefit-risk balance should be continuously monitored while patients are taking montelukast.

A survey of nursing teachers' awareness of discrimination and inequity in telephone nursing care

Background

Nursing care should be respectful of and unrestricted by patients’ age, ethnicity, gender, dis/abilities or social status, and such values should be taught to nursing students. Nursing teachers are crucial as role models, and their values are essential. In telephone nursing, only age, sex and ethnicity are known to the registered nurses, which can be challenging. The aim of this study was to explore awareness of discrimination and inequity in telephone nursing among nursing teachers.

Methods

A study specific survey was filled in by 135 nursing teachers from three universities in Sweden. The survey included short descriptions of 12 fictive persons who differed in age, ethnicity and sex and with questions about their estimated life situation. The teachers’ estimations of life situation were ranked from lowest probability to highest probability. A ‘good life index’ was constructed and calculated for each fictive person. It included quality of life, power over one’s own life and experience of discrimination.

Results

The results indicate that the nursing teachers were aware of how power and age, ethnicity and sex are related; that is, they were aware of discrimination and inequity in healthcare. The persons assessed to be most likely to lead a good life were males of Swedish origin, followed by females of Swedish origin. Persons with non-European origin were estimated to have the highest probability of experiencing discrimination.

Conclusions

The nursing teachers were aware of discrimination and inequity in healthcare. They were able to estimate a fictive person’s life situation based on the limited knowledge of age, ethnicity and sex. This is important, as their values are pivotal in theoretical and practical nursing education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00762-5.

Bi-allelic variants in DNA mismatch repair proteins MutS Homolog MSH4 and MSH5 cause infertility in both sexes

STUDY QUESTION

Do bi-allelic variants in the genes encoding the MSH4/MSH5 heterodimer cause male infertility?

SUMMARY ANSWER

We detected biallelic, (likely) pathogenic variants in MSH5 (4 men) and MSH4 (3 men) in six azoospermic men, demonstrating that genetic variants in these genes are a relevant cause of male infertility.

WHAT IS KNOWN ALREADY

MSH4 and MSH5 form a heterodimer, which is required for prophase of meiosis I. One variant in MSH5 and two variants in MSH4 have been described as causal for premature ovarian insufficiency (POI) in a total of five women, resulting in infertility. Recently, pathogenic variants in MSH4 have been reported in infertile men. So far, no pathogenic variants in MSH5 had been described in males.

STUDY DESIGN, SIZE, DURATION

We utilized exome data from 1305 men included in the Male Reproductive Genomics (MERGE) study, including 90 males with meiotic arrest (MeiA). Independently, exome sequencing was performed in a man with MeiA from a large consanguineous family.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Assuming an autosomal-recessive mode of inheritance, we screened the exome data for rare, biallelic coding variants in MSH4 and MSH5. If possible, segregation analysis in the patients' families was performed. The functional consequences of identified loss-of-function (LoF) variants in MSH5 were studied using heterologous expression of the MSH5 protein in HEK293T cells. The point of arrest during meiosis was determined by γH2AX staining.

MAIN RESULTS AND THE ROLE OF CHANCE

We report for the first time (likely) pathogenic, homozygous variants in MSH5 causing infertility in 2 out of 90 men with MeiA and overall in 4 out of 902 azoospermic men. Additionally, we detected biallelic variants in MSH4 in two men with MeiA and in the sister of one proband with POI. γH2AX staining revealed an arrest in early prophase of meiosis I in individuals with pathogenic MSH4 or MSH5 variants. Heterologous in vitro expression of the detected LoF variants in MSH5 showed that the variant p.(Ala620GlnTer9) resulted in MSH5 protein truncation and the variant p.(Ser26GlnfsTer42) resulted in a complete loss of MSH5.

LARGE SCALE DATA

All variants have been submitted to ClinVar (SCV001468891-SCV001468896 and SCV001591030) and can also be accessed in the Male Fertility Gene Atlas (MFGA).

LIMITATIONS, REASONS FOR CAUTION

By selecting for variants in MSH4 and MSH5, we were able to determine the cause of infertility in six men and one woman, leaving most of the examined individuals without a causal diagnosis.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings have diagnostic value by increasing the number of genes associated with non-obstructive azoospermia with high clinical validity. The analysis of such genes has prognostic consequences for assessing whether men with azoospermia would benefit from a testicular biopsy. We also provide further evidence that MeiA in men and POI in women share the same genetic causes.

STUDY FUNDING/COMPETING INTEREST(S)

This study was carried out within the frame of the German Research Foundation sponsored Clinical Research Unit 'Male Germ Cells: from Genes to Function' (DFG, CRU326), and supported by institutional funding of the Research Institute Amsterdam Reproduction and Development and funds from the LucaBella Foundation. The authors declare no conflict of interest.

Better safe than sorry: Registered nurses' strategies for handling difficult calls to emergency medical dispatch centres - An interview study

AIMS AND OBJECTIVES

To describe strategies employed by registered nurses for handling difficult calls to emergency medical dispatch centres.

BACKGROUND

At emergency medical dispatch centres, registered nurses encounter a range of difficult calls in their clinical practice. They often use clinical decision support systems, but these may be of limited help if the caller is for instance abusive or has limited language proficiency. Much can be learnt from strategies developed by registered nurses for handling difficult calls.

DESIGN

A descriptive qualitative study was conducted.

METHODS

A purposeful sample of 24 registered nurses from three different emergency medical dispatch centres were interviewed. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was applied.

RESULTS

An overarching theme was established: "Using one's nursing competence and available resources for a safe outcome", based on three sub-themes: Use one's own professional and personal resources, Use resources within the organisation and Use external resources. The themes in turn consist of ten categories.

CONCLUSIONS

Registered nurses employed a range of strategies to deal with difficult calls, often in combination. They used their personal resources, resources within their own organisation, and collaboration partners to make safe triage decisions and use resources wisely. The effectiveness of these strategies, however, remains unknown. When registered nurses were unable to rule out a high-acuity condition, they used safety-netting and sent an ambulance. Evaluating current strategies and making strategies explicit could further improve the ability of nurses to handle difficult calls.

RELEVANCE TO CLINICAL PRACTICE

The strategies described by registered nurses for handling difficult calls to EMDCs included using a consecutive set of strategies. Some of the strategies seemed to be used deliberately, while others seemed tacit and applied in a routinised way. These strategies could potentially be useful for RNs working with telephone triage in different contexts.

Telephone nurses' perceived stress, self-efficacy and empathy in their work with frequent callers

Aim

To examine telephone nurses' perceived stress, self‐efficacy and empathy in their work with answering calls from frequent callers.

Design

The study is a quantitative questionnaire survey study with a comparative design.

Methods

Telephone nurses (N = 199) answered a survey containing three instruments: Perceived Stress Scale, General Self‐Efficacy Scale and Jefferson's Scale of Empathy. Correlation analysis, multiple regression analysis and analysis of variance were performed to test the research questions.

Results

Significant negative correlations were found between stress involving calls from FCs and self‐efficacy (r = −.238), and significant negative correlations between stress involving calls from frequent callers and empathy (r = −.185). It was further revealed that telephone nurses who had worked less than 30 years scored higher on Jefferson's Scale of empathy than those who had worked more than 30 years, F(1, 183) = 4.98, η² = 0.027.

The perspectives of Swedish registered nurses about managing difficult calls to emergency medical dispatch centres: a qualitative descriptive study

Background

Telephone triage at emergency medical dispatch centres is often challenging for registered nurses due to lack of visual cues, lack of knowledge about the patient, and time pressure – and making the right decision can be a matter of life and death. Some calls may be more difficult to handle, and more knowledge is needed about these calls to develop education and coping strategies. Therefore, the aim of this study was to describe the perspectives of registered nurses’ views about managing difficult calls to emergency medical dispatch centres.

Methods

A descriptive design with a qualitative inductive approach was used. Three dispatch centers in mid-Sweden were investigated, covering about 950,000 inhabitants and handling around 114,000 calls per year. Individual interviews were carried out with a purposeful sample of 24 registered nurses. Systematic text condensation was conducted.

Results

Seven themes were generated: calls with communication barriers, calls from agitated or rude callers, calls about psychiatric illness, calls from third parties, calls about rare or unclear situations, calls with unknown addresses and calls regarding immediate life-threatening conditions. There was a strong consensus among the registered nurses about which calls were experienced as difficult, with the exception of calls about immediate life-threatening conditions. Some registered nurses thought calls about immediate life-threatening conditions were easy to handle as they simply adhered to protocol, while others described these calls as difficult and were emotionally affected.

Conclusion

The registered nurses’ descriptions of difficult calls focused on the callers, while their own role, the organisational framework, and leadership were not mentioned. Many types of calls included difficulties, which could be related to the caller, their symptoms, or different circumstances. The registered nurses pointed to language barriers and rude, agitated callers as increasing problems. An investigation of actual emergency calls is warranted to examine the extent and nature of such calls.

Characterization of VigiBase reports on tinnitus associated with bisoprolol—An exploratory and descriptive study

The aim of this descriptive and explorative study was to assess individual case safety reports of bisoprolol associated with tinnitus and investigate their added value in information about adverse drug reactions (ADRs) in relation to information provided in medicine labels. The global reports from VigiBase, the WHO database of individual case safety reports, as of May 3, 2020, were analyzed for information about bisoprolol associated with tinnitus as an ADR affecting the quality of life of the patients. There were 123 reports of the ADR tinnitus reported with intake of bisoprolol in VigiBase. These described experiences of tinnitus and how this impacted on patients’ daily life, for example, it could be long‐lasting and may have negative impact on sleeping, and even ability to work and keep a job. There were also reports describing the management of the reaction, for example, recovery upon stopping the treatment, and improvement of the symptoms following a decreased dose or change of medicine batch. Based on reports in VigiBase, the ADR tinnitus associated with bisoprolol suggests vigilance for the onset of the event and that, if it occurs, a dose reduction or stopping the treatment could be necessary. The information provided in the reports shows the value of individual case safety reports collected post marketing, in providing descriptive information of the experience and management of the ADR.

Registered nurses' understandings of emergency medical dispatch center work: A qualitative phenomenographic interview study

Non-urgent and urgent telephone nursing services are increasing globally, and phenomenographic research has shown that how work is understood may influence work performance. This descriptive study makes a qualitative inductive investigation of understandings of emergency medical dispatch center work among registered nurses. Twenty-four registered nurses at three mid Swedish emergency medical dispatch centers were interviewed. Analysis based on phenomenographic principles identified five categories in the interviews: (i) Assess, prioritize, direct, or refer; (ii) Facilitate ambulance nursing work; (iii) Perform nursing care; (iv) Always be available for the public; and (v) Have the person behind the patient in mind. The first constitutes the basis of the work. The second emphasizes cooperation with and support for the ambulance staff. The third entails remotely providing nursing care, whilst the fourth stresses serving the entire population. The fifth and most comprehensive way of understanding work involves having a holistic view of the person in need, including person-centered care. Provision of high-quality emergency medical dispatch center work involves all categories. Combined, they constitute a "work map," valuable for reflection, competence development, and introduction of new staff.

Liver cirrhosis turns life into an unpredictable roller coaster: A qualitative interview study

Aim

To explore how persons living with liver cirrhosis experience day‐to‐day life.

Background

Liver cirrhosis is the sixth most common cause of death among adults in Western countries. Persons with advanced liver cirrhosis report poor quality of life, in comparison with other chronic diseases. However, knowledge regarding day‐to‐day life during earlier stages of the disease is lacking. In other chronic diseases, the suffering process is well explored, while in liver cirrhosis, suffering is insufficiently investigated.

Design

An exploratory study, with a qualitative inductive interview approach.

Methods

A purposive maximum variation sample of 20 informants with liver cirrhosis aged 25–71, from two gastroenterology outpatient clinics in mid‐Sweden, were interviewed from September 2016 to October 2017. Interview data were analysed inductively with qualitative content analysis. Reporting followed the COREQ guidelines.

Results

The experiences of day‐to‐day life living with liver cirrhosis comprised four sub‐themes. Living with liver cirrhosis implied varying levels of deterioration, the most apparent being exhaustion or tiredness. The informants had to find ways of adapting to a new life situation. The insecurity of future health evoked existential reflections such as feeling emotionally and existentially distressed. Shame and guilt were reasons for feeling stigmatised. These sub‐themes emerged into one overarching theme of meaning: life turns into an unpredictable roller coaster. This is based on experiences of liver cirrhosis as an unpredictable disease with fluctuating symptoms, worries and disease progression.

Conclusion

Living with cirrhosis implies an unpredictable condition with a progressive, stigmatising disease. The fluctuating symptoms and deep concerns about future life pose an increased personal suffering.

Relevance to clinical practice

Within health care, knowledge of the person's experience is vital to enable and fulfil the person's healthcare needs. Clinical registered nurses need a person‐centred approach to strengthen their patients to cope with their new life situation.

Registered nurses´ views on telephone nursing for patients with respiratory tract infections in primary healthcare - a qualitative interview study

Background

Telephone nursing in primary healthcare has been suggested as a solution to the increased demand for easy access to healthcare, increased number of patients with complex problems, and lack of general practitioners. Registered nurses’ assessments may also be of great importance for antibiotic prescriptions according to guidelines. The aim of this study was to describe registered nurses’ views of telephone nursing work with callers contacting primary healthcare centres regarding respiratory tract infections.

Methods

A descriptive, qualitative study was performed through interviews with twelve registered nurses in Swedish primary healthcare.

Results

The overarching themes for registered nurses’ views on telephone nursing were captured in two themes: professional challenges and professional support. These included three and two categories respectively: Communicate for optimal patient information; Differentiate harmless from severe problems; Cope with caller expectations; Use working tools; and Use team collaboration. Optimal communication for sufficiently grasping caller symptoms and assess whether harmful or not, without visual input, was underlined. This generated fear of missing something serious. Professional support used in work, were for example guidelines and decision support tool. Colleagues and teamwork collaboration were requested, but not always offered, support for the interviewed registered nurses.

Conclusions

The study deepens the understanding of telephone nursing as an important factor for decreasing respiratory tract infection consultations with general practitioners, thus contributing to decreased antibiotic usage in Sweden. To cope with the challenges of telephone nursing in primary healthcare centres, it seems important to systematically introduce the use of the available decision support tool, and set aside time for inter- and intraprofessional discussions and feedback. The collegial support and team collaboration asked for is likely to get synergy effects such as better work environment and job satisfaction for both registered nurses and general practitioners. Future studies are needed to explore telephone nursing in primary healthcare centres in a broader sense to better understand the function and the effects in the complexity of primary healthcare.

A survey of telephone nurses' experiences in their encounters with frequent callers

AIM

The aim of this study was to describe telephone nurses' experiences of their encounters with frequent callers to Swedish Healthcare Direct.

DESIGN

A descriptive inductive design with qualitative approach.

METHODS

Data collection was performed during the period of September 2017 - June 2018. A total of 199 telephone nurses working at 10 Swedish Healthcare Direct sites with different geographical locations in Sweden answered a survey containing seven open-ended questions. Data analysis was performed during the period of September 2018 - June 2019. The answers were analysed using content analysis.

RESULTS

The telephone nurses perceived that the encounters with frequent callers were sometimes frustrating as they felt unable to help. According to the telephone nurses, the frequent callers called about the same issues several times and the calls were often about loneliness and psychiatric problems. The telephone nurses were worried about missing something urgent; one of the aspects leading to this was the perception of knowing the caller. They expressed a wish to know more about frequent callers and strategies for helping them. A common care plan for frequent callers' calls was suggested.

CONCLUSION

Telephone nurses often found it difficult to handle calls from frequent callers. However, they had a will to care for frequent callers and to learn more about them. Therefore, a common strategy, education and training for telephone nurses in answering calls from frequent callers could be beneficial for both callers and telephone nurses.

IMPACT STATEMENT

This study offers insights to researchers, telephone nurses and managers of telephone nursing, regarding telephone nurses' experiences in handling frequent caller calls. These findings can offer direction for the content of a possible intervention.

Swedish Healthcare Direct managers' views on gender (in)equity: applying a conceptual model

Background

Although Swedish legislation prescribes equity in healthcare, inequitable healthcare is repeatedly reported in Sweden. Telephone nursing is suggested to promote equitable healthcare, making it just one call away for anyone, at any time, irrespective of distance. However, paediatric health calls reflect that male parents are referred to other health services twice as much as female parents are. Regarding equity in healthcare, telephone nurses have expressed a continuum from Denial and Defence to Openness and Awareness. To make a change, Action is also needed, within organizational frames. The aim here was thus to investigate Swedish Healthcare Direct managers’ views on gender (in)equity in healthcare through the application of a conceptual model, developed based on empirical Swedish Healthcare Direct telephone RN data, as a baseline measure at the service’s national implementation.

Methods

All Swedish Healthcare Direct managers were interviewed during the period March–May 2012. They were asked how they view equitable healthcare, and how they work to achieve it. A conceptual model for attaining equity in healthcare, including Denial, Defence, Openness, Awareness and Action, was used in a deductive thematic analysis of the interview data.

Results

The five model concepts – Denial; Defence; Openness; Awareness and Action – were found in a variety of combinations in the manager interviews. Denial and Defence were mentioned to a higher extent than Openness and Awareness. Several informants denied inequity, arguing that the decision support tool prevented this. However, those who primarily expressed Denial and Defence were also open to learning more on the subject. Action was only mentioned twice in the informants’ answers, and then only implicitly.

Conclusion

Although a majority of the interviewed managers expressed a lack of awareness of (in)equity in healthcare, they also expressed an openness to learning more. While this may reflect a desire to show political correctness, it also points to the need for educational training in order to increase the awareness of (in)equity in healthcare among healthcare managers. Future follow up measurements will reveal if this has happened.

Gaining role clarity in working with sick leave questions-Registered Nurses' experiences of an educational intervention

AIM

To describe how a short educational intervention in social insurance medicine was experienced by Registered Nurses and what changes it brought to their work with sick leave questions in telephone nursing.

DESIGN

Qualitative explorative interview study.

METHODS

Interviews with 12 purposively sampled Registered Nurses were conducted and analysed using manifest content analysis.

RESULTS

The intervention increased Registered Nurses' knowledge of the sick leave process and changed their work habits as they now have more of the skills needed to handle sick leave questions. In this way, they gained role clarity in their work with sick leave questions. The new knowledge included rules and regulations, actors' roles and patients' experiences. Learning from peers, reflecting and having the opportunity to ask questions were also described as increasing their knowledge. The skills following the participation were described as knowing what to say and do and knowing where to turn for support.

"Same same or different?" A review of reviews of person-centered and patient-centered care

OBJECTIVE

To provide a synthesis of already synthesized literature on person-centered care and patient-centered care in order to identify similarities and differences between the two concepts.

METHODS

A synthesis of reviews was conducted to locate synthesized literature published between January 2000 and March 2017. A total of 21 articles deemed relevant to this overview were synthesized using a thematic analysis.

RESULTS

The analysis resulted in nine themes present in person-centered as well as in patient-centered care: (1) empathy, (2), respect (3), engagement, (4), relationship, (5) communication, (6) shared decision-making, (7) holistic focus, (8), individualized focus, and (9) coordinated care. The analysis also revealed that the goal of person-centered care is a meaningful life while the goal of patient-centered care is a functional life.

CONCLUSIONS

While there are a number of similarities between the two concepts, the goals for person-centered and patient-centered care differ. The similarities are at the surface and there are important differences when the concepts are regarded in light of their different goals.

PRACTICE IMPLICATIONS

Clarification of the concepts may assist practitioners to develop the relevant aspects of care. Person-centered care broadens and extends the perspective of patient-centered care by considering the whole life of the patient.

Nurse-led clinic for patients with liver cirrhosis-effects on health-related quality of life: study protocol of a pragmatic multicentre randomised controlled trial

INTRODUCTION

Liver cirrhosis affects health-related quality of life (HRQoL) even in its early stages. Morbidity is especially high when the disease decompensates and self-care actions become essential. Nurse involvement in secondary prevention in other chronic diseases has contributed to better symptom control, less need of inpatient care and improved HRQoL. In order to evaluate the impact of nurse involvement in the follow-up of patients with liver cirrhosis, we decided to compare structured nurse-led clinics, inspired by Dorothea Orem's nursing theory and motivational strategies, with a group of patients receiving standard care. The primary outcome is HRQoL and the secondary outcomes are quality of care, visits to outpatient clinics or hospitals, disease progress and health literacy.

METHODS AND ANALYSIS

This is a pragmatic, multicentre randomised controlled study conducted at six Swedish hepatology departments. Eligible patients are adults with diagnosed cirrhosis of the liver (n=500). Participants are randomised into either an intervention with nurse-led follow-up group or into a standard of care group. Recruitment started in November 2016 and is expected to proceed until 2020. Primary outcomes are physical and mental HRQoL measured by RAND-36 at enrolment, after 1 and 2 years.

ETHICS AND DISSEMINATION

The study is ethically approved by the Regional Ethical Review Board in Uppsala. The results shall be disseminated in international conferences and peer-reviewed articles.

TRIAL REGISTRATION NUMBER

NCT02957253; Pre-results.

Action of Newcastle Disease Virus on Human Blood Platelets

Newcastle Disease Virus induces a viscous metamorphosis like process in washed platelets.

This virus liberates from platelets lactic dehydrogenase and pyruvate kinase, depletes their ATP content and impairs their ability to concentrate 5-hydroxy-tryptamine.

Since Newcastle Disease Virus has adenosine triphosphatase activity, a possible role of this viral enzyme in the production of viscous metamorphosis and in inhibition of clot retraction is discussed.

Treatment of platelets by Newcastle Disease Virus or by particulate fraction from normal allantoic fluid causes liberation of a platelet factor 3-like substance.

From denial to awareness: a conceptual model for obtaining equity in healthcare

Background

Although Swedish legislation prescribes equity in healthcare, studies have reported inequalities, both in face-to-face encounters and in telephone nursing. Research has suggested that telephone nursing has the capability to increase equity in healthcare, as it is open to all and not limited by long distances. However, this requires an increased awareness of equity in healthcare among telephone nurses.

The aim of this study was to explore and describe perceptions of equity in healthcare among Swedish telephone nurses who had participated in an educational intervention on equity in health, including which of the power constructs gender, ethnicity and age they commented upon most frequently. Further, the aim was to develop a conceptual model for obtaining equity in healthcare, based on the results of the empirical investigation.

Method

A qualitative method was used. Free text comments from questionnaires filled out by 133 telephone nurses before and after an educational intervention on equity in health, as well as individual interviews with five participants, were analyzed qualitatively. The number of comments related to inequity based on gender, ethnicity or age in the free text comments was counted descriptively.

Results

Gender was the factor commented upon the least and ethnicity the most. Four concepts were found through the qualitative analysis: Denial, Defense, Openness, and Awareness. Some informants denied inequity in healthcare in general, and in telephone nursing in particular. Others acknowledged it, but argued that they had workplace routines that protected against it. There were also examples of an openness to the fact that inequity existed and a willingness to learn and prevent it, as well as an already high awareness of inequity in healthcare.

Conclusion

A conceptual model was developed in which the four concepts were divided into two qualitatively different blocks, with Denial and Defense on one side of a continuum and Openness and Awareness on the other. In order to reach equity in healthcare, action is also needed, and that concept was therefore added to the model. The result can be used as a starting point when developing educational interventions for healthcare personnel.

Nursing students' awareness of inequity in healthcare - An intersectional perspective

OBJECTIVE

The overall aim of the present study was to explore awareness of inequity in healthcare and the intersection between different structures of power among nursing students. Another aim was to delineate the knowledge and use of Swedish Healthcare Direct in this group.

DESIGN

The study had a descriptive design with a quantitative approach.

PARTICIPANTS

The sample consisted of 157 nursing students from three universities in central Sweden.

METHODS

The students filled out a study specific questionnaire in class. The questionnaire consisted of short descriptions of twelve fictive persons who differed in gender, age, and ethnicity, with questions about their life situation. The mean was calculated for each assessed fictive person for every item. In the next step, the assessments were ranked from the lowest probability to the highest probability. A 'Good life-index' consisting of quality of life, power over own life, and experience of discrimination, was also calculated. Free text comments were analysed qualitatively.

RESULTS

People with Swedish names were assessed to have the highest probability of having a good life. Among those with Swedish names, the oldest woman was assessed as having the lowest probability of a good life. All students had knowledge about Swedish Healthcare Direct, but more female students had used the service compared to male students.

CONCLUSIONS

The results indicate that the nursing students had awareness of how power and gender, ethnicity and age, are related. Based on the free text comments, the questions and the intersectional perspective seemed to evoke some irritation which points to their sensitive nature. Therefore, the questionnaire could be used as a tool to start a discussion of equity in healthcare and in interventions where the aim is to raise awareness of inequality and intersectionality.

Impact of telephone nursing education program for equity in healthcare

BACKGROUND

The Swedish Healthcare Act prescribes that healthcare should be provided according to needs and with respect for each person's human dignity. The goal is equity in health for the whole population. In spite of this, studies have revealed that Swedish healthcare is not always provided equally. This has also been observed in telephone nursing. Therefore, the aim of the present study was to investigate if and how an educational intervention can improve awareness of equity in healthcare among telephone nurses.

METHODS

The study had a quasi-experimental design, with one intervention group and one control group. A base-line measurement was performed before an educational intervention and a follow-up measurement was made afterwards in both groups, using a study specific questionnaire in which fictive persons of different age, gender and ethnicity were assessed concerning, e.g., power over one's own life, quality of life and experience of discrimination. The educational intervention consisted of a web-based lecture, literature and a seminar, covering aspects of inequality in healthcare related to gender, age and ethnicity, and gender and intersectionality theories as explaining models for these conditions.

RESULTS

The results showed few significant differences before and after the intervention in the intervention group. Also in the control group few significant differences were found in the second measurement, although no intervention was performed in that group. The reason might be that the instrument used was not sensitive enough to pick up an expected raised awareness of equity in healthcare, or that solely the act of filling out the questionnaire can create a sort of intervention effect. Fictive persons born in Sweden and of young age were assessed to have a higher Good life-index than the fictive persons born outside Europe and of higher age in all assessments.

CONCLUSION

The results are an imperative that equity in healthcare still needs to be educated and discussed in different healthcare settings. The intervention and questionnaire were designed to fit telephone nurses, but could easily be adjusted to suit other professional groups, who need to increase their awareness of equity in healthcare.

Goals of telephone nursing work--the managers' perspectives: a qualitative study on Swedish Healthcare Direct

BACKGROUND

Swedish Healthcare Direct (SHD) receives 6 million calls yearly and aims at increased public sense of security and healthcare efficiency. Little is known about what SHD managers perceive as the primary goals of telephone nursing (TN) work and how the organisation matches goals of health promotion and equitable healthcare, so important in Swedish healthcare legislation. The aim of the study was to explore and describe what the SHD managers perceive as the goals of TN work and how the managers view health promotion and implementation of equitable healthcare with gender as example at SHD.

METHODS

The study was qualitative using an exploratory and descriptive design. All 23 managers employed at SHD were interviewed and data analysis used deductive directed content analysis.

RESULTS

The findings reveal four themes describing the goals of TN work as recommended by the SHD managers. These are: 'create feelings of trust', 'achieve patient safety', 'assess, refer and give advice', and 'teach the caller'. Most of the managers stated that health promotion should not be included in the goals, whereas equitable healthcare was viewed as an important issue. Varying suggestions for implementing equitable healthcare were given.

CONCLUSIONS

The interviewed managers mainly echoed the organisational goals of TN work. The managers' expressed goal of teaching lacked the caller learning components highlighted by telenurses in previous research. The fact that health promotion was not seen as important indicates a need for SHD to clarify its goals as the organisation is part of the Swedish healthcare system, where health promotion should always permeate work. Time used for health promotion and dialogues in a gender equitable manner at SHD is well invested as it will save time elsewhere in the health care system, thereby facing one of the challenges of European health systems.

A new mutation in the menin gene causes the multiple endocrine neoplasia type 1 syndrome with adrenocortical carcinoma

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant tumor syndrome that may be caused by mutations in the MEN1 gene on 11q13. Loss of function of the tumor suppressor gene MEN1 leads to synchronous or metachronous appearance of neuroendocrine tumors arising from neuroendocrine cells of the parathyroid and pituitary glands, the duodenum and pancreatic islets, and other endocrine organs such as the adrenal cortex. We here present a patient with MEN1 who developed hyperparathyroidism, multiple well differentiated functionally inactive neuroendocrine tumors of the pancreas and an adrenal carcinoma. We describe a new mutation at codon 443 in the coding region of exon 9 in the MEN1 gene, where a cytosine residue was exchanged for adenosine (TCC > TAC) and, consequently, serine for tyrosine (p.Ser443Tyr; c.1328C > A). [corrected] Also, we provide clinical data that may add to the genotype-phenotype discussion. We conclude that the novel mutation in the MEN1 gene described herein was clinically relevant.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

[Multiple endocrine neoplasia 2a: late manifestation of a newly-discovered mutation]

HISTORY

A 55-year-old patient presented with a painless right-sided cervical swelling, which had been present for four months and seemed to get larger. The patient denied dyspnea, dysphagia, "a lump in the throat" or thyroid disease. Two of his paternal aunts had thyroid carcinoma and an adrenal tumor.

INVESTIGATIONS

Ultrasonography revealed an enlarged lymphoid nodule and a large lesion in the right thyroid lobe, the latter with deficient technetium uptake on scintigraphy.

THERAPY AND COURSE

A total thyroidectomy with bilateral centrocervical and lateral neck dissection was performed. Histology revealed a bilateral medullary thyroid carcinoma [MTC: pT3, pN1b (9/34), pM0 (UICC 2002)] and the genetic screening showed a double mutation in codon 611 (TGC>TAT; p.Cys611Tyr; C611Y), and exon 10 of the RET proto-oncogene, which has not been described before. Pheochromocytoma and hyperparathyroidism were excluded. Genetic screening of all close family members was initiated and showed that four of them were gene carriers. Three of them have been operated and a MTC found.

CONCLUSION

The described newly discovered mutation is associated with MTC and pheochromocytoma. This case underlines the need of genetic screening in all patients who present with a MTC only, no matter what the person's age of manifestation, even in the absence of any other MEN-related disease.

Induction of mRNA for tumor necrosis factor-alpha and interleukin-1 beta in mice brain, spleen and liver in an animal model of Shigella-related seizures

BACKGROUND

The pathogenesis of neurological symptoms, the most common extraintestinal complication of childhood shigellosis, is unclear. To elucidate the mechanisms involved, we developed an animal model and demonstrated that TNF alpha and IL-1 beta play a role.

OBJECTIVES

To determine whether TNF alpha and IL-1 beta genes are expressed in the brain following peripheral administration of Shigella dysenteriae 60R.

METHODS

Expression of mRNA for TNF alpha and IL-1 beta was examined in the brain structures (hypothalamus and hippocampus) and peripheral organs by reverse transcriptase polymerase chain reaction, at different time points after intraperitoneal injection of S. dysenteriae sonicate.

RESULTS

In our animal model of Shigella-related seizures, TNF alpha and IL-1 beta mRNA were induced in the brain, spleen and liver already 1 hour after injection of S. dysenteriae sonicate. The expression of TNF alpha and IL-1 beta mRNA in spleen, hippocampus and hypothalamus decreased after 6 h and increased again at 18 h post-injection.

CONCLUSIONS

Local production of TNF alpha and IL-1 beta in the brain may be involved in the enhanced seizure response of mice after administration of S. dysenteriae. It is possible that intracerebral production of TNF alpha and IL-1 beta plays a role in neurological disturbances of human shigellosis.

Role of nitric oxide in the enhancement of pentylenetetrazole-induced seizures caused by Shigella dysenteriae

Convulsions and encephalopathy are frequent complications of childhood shigellosis. We studied the role of nitric oxide (NO) in Shigella-related seizures in an animal model. Pretreatment of mice with Shigella dysenteriae 60R sonicate elevated serum NO levels and enhanced the convulsive response to pentylenetetrazole (PTZ), as indicated by a higher mean convulsion score and a higher number of mice responding with seizures. Treatment of the mice with S-methylisothiourea sulfate (SMT), a potent inhibitor of inducible NO synthase (NOS), prevented the elevation of serum NO levels and concomitantly reduced the enhanced response to PTZ. The mean convulsion scores were 0.7, 0.7, 1.3, and 0.8 for mice treated with saline, saline and SMT, S. dysenteriae 60R sonicate, and S. dysenteriae 60R sonicate with SMT, respectively (P = 0.001 for 60R sonicate versus saline and P = 0.013 for 60R sonicate versus 60R sonicate with SMT). The corresponding seizure rates were 40, 44, 75, and 47% for saline, saline with SMT, S. dysenteriae 60R sonicate, and S. dysenteriae 60R sonicate with SMT, respectively (P = 0.0004 for 60R sonicate versus saline and P = 0.005 for 60R sonicate versus 60R sonicate with SMT). In contrast, injection of N-nitro-L-arginine, a selective inhibitor of constitutive NOS, neither abolished the elevation of serum NO nor attenuated the enhancement of seizures. These findings indicate that NO, induced by S. dysenteriae 60R sonicate, is involved in enhancing the susceptibility to seizures caused by S. dysenteriae.

Involvement of tumor necrosis factor alpha and interleukin-1beta in enhancement of pentylenetetrazole-induced seizures caused by Shigella dysenteriae

Neurologic manifestations, mainly convulsions, are the most frequent extraintestinal complications of shigellosis. We used an animal model to study the roles of tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta) in Shigella-related seizures. Administration of Shigella dysenteriae 60R sonicate enhanced the sensitivity of mice to the proconvulsant pentylenetetrazole (PTZ) within 7 h. This was indicated by a significantly higher mean convulsion score and an increased number of mice responding with clonic-tonic seizures in the Shigella-pretreated group. Preinjection of mice with anti-murine TNF-alpha (anti-mTNF-alpha) or anti-murine IL-1beta (anti-mIL-1beta) 30 min prior to administration of Shigella sonicate abolished their enhanced response to PTZ at 7 h. Mean convulsion scores were reduced by anti-mTNF-alpha from 1.2 to 0.8 (P = 0.017) and by anti-mIL-1beta from 1.3 to 0.7 (P = 0.008). Preinjection of anti-mTNF-alpha also reduced the percentage of mice responding with clonic-tonic seizures, from 48 to 29% (P = 0.002), and preinjection of anti-mIL-1beta reduced it from 53 to 21% (P = 0. 012). Neutralization of TNF-alpha or IL-1beta did not protect the mice from death due to S. dysenteriae 60R. These findings indicate that TNF-alpha and IL-1beta play a role in the very early sensitization of the central nervous system to convulsive activity after S. dysenteriae administration. Similar mechanisms may trigger neurologic disturbances in other infectious diseases.

Induction of tumor necrosis factor and nitric oxide by Shigella strains isolated from patients with or without neurologic manifestations

The pathogenesis of the Shigella-associated neurological symptoms is unclear. We examined the potential role of host factors. Sonicates of Shigella strains isolated from children with and without neurologic disturbances were compared regarding their ability to induce tumor necrosis factor (TNF) and nitric oxide (NO) in vitro, in mouse macrophage J744 cell line. The mean concentrations of TNF (14.6 vs. 4.4 ng/ml) and NO (7.4 vs. 3.7 microM) induced were higher in response to strains isolated from children with neurologic complications; the differences were not statistically significant. TNF was also measured in plasma of children with shigellosis, and was found to be elevated in all patients. The mean concentration of TNF in plasma of children with neurologic manifestations was higher than that of children with no neurologic symptoms (450 vs. 138 pg/ml, P <0.05). It is concluded that TNF and NO may play a role in the development of neurologic manifestations of shigellosis.

Induction of nitric oxide production in mouse macrophages by Shiga toxin

Host mediators play an important role in the pathogenesis of shigellosis and Shiga toxin toxicity. Nitric oxide (NO) production in mouse peritoneal macrophages and in the macrophage J744 cell line in response to purified Shiga toxin and lipopolysaccharide (LPS) from Shigella flexneri were studied. Shiga toxin induced NO production in a dose-dependent manner up to 800 ng/ml. Detectable levels of NO were present as early as 4 h after induction and continued to increase during 72 h; Shiga toxin induced greater NO production with time than did LPS. Pre-treatment of Shiga toxin (400 ng/ml) or LPS (10 ng/ml) with polymyxin B, which inactivates LPS, reduced their ability to induce NO by 28% and 96%, respectively. Induction in the presence of anti-TNF alpha antibodies did not reduce the amount of NO in the supernate. These studies showed that Shiga toxin induces NO production in murine macrophages.

The immunosuppressive human placental ferritin subunit p43 is produced by activated CD4+ lymphocytes

Human placental ferritin is an immunosuppressive protein composed of a 43-kDa subunit (p43) and ferritin light chains. Its physiological action seems to be downregulation of the immune response of the mother against her embryo. Elevated levels of p43 in serum are associated with pregnancy, lymphomas, breast cancer, and AIDS. Although it is known that p43 is produced by activated T lymphocytes, the specific T-lymphocyte subset involved is unknown. p43 is measured by enzyme-linked immunosorbent assays with CM-H-9 monoclonal antibody specific for p43. We studied the de novo biosynthesis of p43 by isolated activated CD4+ and CD8+ T lymphocytes in a normal donor and in a patient with elevated levels of p43 in serum. The results indicated that p43 was synthesized by activated CD4+ lymphocytes from the normal donor (0.45% of the total de novo proteins) but that its biosynthesis by CD8+ lymphocytes was below the level of detection. The activated CD4+ lymphocytes from the patient with elevated levels of p43 in serum overproduced p43 (3.8% of the nascent proteins). Since it was shown that a subset of CD8+ lymphocytes has receptors for p43, the latter may be considered an immunoregulatory cytokine produced mainly by activated CD4+ lymphocytes.

The effect of shiga toxin and sonicates of Shigella isolates from children with neurologic manifestation on neuroblastoma cell lines

Although neurologic manifestations are frequent during childhood shigellosis, their pathogenesis is unclear and controversial. Shiga toxin and other cytotoxins are often implicated, but their effect on neuronal cells has not been determined. We examined the effect of purified Shiga toxin and sonicates of Shigella isolates from children with neurologic symptoms on well-characterized human neuroblastoma cells in vitro. Quantitative determinations showed high cytotoxicity of Shiga toxin on HeLa cells (1.2 x 10(6) CD50/mg purified toxin), but no effect on LA-N-1, LA-N-5 and IMR neuroblastoma cell lines. Pretreatment with tumor necrosis factor, which increases expression of the Shiga toxin receptor, globotriosyl ceramide, in endothelial cells and enhanced Shiga toxin cytotoxicity, did not affect the susceptibility of neuroblastoma cells to the toxin. Low dilutions (up to 1:16-1:64) of sonicates of Shigella isolates from children with neurologic symptoms caused agglutination of neuroblastoma cells, but no cell killing was observed morphologically. This study shows that Shiga toxin does not exhibit cytotoxic activity on the human neuroblastoma cell lines examined, neither do sonicates of relevant Shigella strains. The mechanism and significance of the agglutination activity on neuroblastoma cells should be further studied.

Mosaicism in 45,X Turner syndrome: does survival in early pregnancy depend on the presence of two sex chromosomes?

Cytogenetic and molecular genetic findings in 91 patients with Turner syndrome are reported. In 87 patients, chromosome studies were carried out both in lymphocyte and fibroblast cultures. Mosaicism was demonstrated in 58 of these patients (66.7%), whereas only 18 (20.7%) were apparent non-mosaic 45,X, and 11 patients (12.6%) showed non-mosaic structural aberrations of the X chromosome. Among the mosaic cases 16 (18.4% of all patients) displayed a second cell line containing small marker chromosomes. The association of Y-specific chromosomal material with the presence of marker chromosomes was demonstrated in 6 out of 7 mixoploid fibroblast cell lines by polymerase chain reaction amplification and by Southern-blot analysis. The observation of ring formation and morphological variability in vivo and in vitro, and the continuous reduction in the percentage of cells containing marker chromosomes in longterm cultivation experiments indicated an increased instability of marker chromosomes. The findings suggest that in vivo selection of structurally altered sex chromosomes exists. Thus, the observation of apparent non-mosaic 45,X chromosomal complements in liveborn individuals with Turner syndrome does not contradict the hypothesis that some degree of mosaicism is necessary for survival in early pregnancy.

Dimethyl sulfoxide-induced differentiation does not alter tumorigenicity of neuroblastoma cells

It has been shown that agents that are known to be scavengers of hydroxyl radicals may induce differentiation and inhibit growth of murine neuroblastoma cells in tissue culture. The present study tests dimethyl sulfoxide as a differentiation agent of the human neuroblastoma cell lines LA-N-1 and murine neuroblastoma NIE-115. Results indicate that DMSO induces morphologic and biochemical differentiation of neuroblastoma cells coupled to growth inhibition and inhibition of colony formation in semi liquid tissue culture systems. DMSO treatment in vitro had no effect on tumorigenicity of NIE-115 cells. In vivo DMSO treatment of athymic nude mice with transplanted LA-N-1 human neuroblastoma tumors has not affected tumor size or animal survival. No diminishing effect of natural killer cell activity could be attributed to DMSO treatment.

Rabbit skeletal muscle F-actin can be stable at low ionic strength, provided trace amounts of Ca2+ are absent

Addition of low concentrations (0.2--2.0 mM) of EGTA to rabbit skeletal muscle G-actin in the presence of ATP caused increase in viscosity. The effect is probably due to chelation of Ca2+. EGTA-polymerized actin was sedimented in the ultracentrifuge as a pellet which could be depolymerized in the presence of Ca2+ and then repolymerized. Electron microscopy indicated that formation of filamentous actin which appears to be somewhat more flexible than F-actin obtained by polymerization with KCl. The EGTA-polymerized actin was dissociated by DNAase I faster than KCl-polymerized actin. F-Actin can thus be stable also in very low ionic strength media if Ca2+ is removed whereas for G-actin to be the only form of the protein in such media, micromolar concentrations of Ca2+ must be present.