Critical care nurses' perception of patient involvement in care: A qualitative focus group.

BACKGROUND: Patient involvement in care in the intensive care unit (ICU) is complex. Knowledge about the nature and extent of patient involvement in the Intensive care unit is scarce. AIM: The aim of the study was to explore the critical care nursing staff's perception of patient involvement in their care in the ICU. STUDY DESIGN: A phenomenological, hermeneutic research study was carried out using qualitative data. Data were collected in two focus group interviews analysed using Ricoeur's theory of interpretation. The study was conducted in a level 2 medical-surgical 8-bed ICU in a regional hospital in Southern Denmark. RESULTS: Critical care nurses found it important to maintain involvement in intensive care. Depending on the patient's ability to partake in care, approaches for patient involvement ranged from (1) continually adjusting care activities according to the patient's bodily responses, (2) formation of a relationship with the patient to enable personalized care and (3) making room for self-determined care progressing with the patient's recovery. CONCLUSION: Critical care nurses' perception of patient involvement depended on the patient's level of consciousness. When unconscious, patient involvement was possible but took a physical approach. However, the power inequality in the nurse-patient relationship must be expressed if patient involvement in the ICU is to take place. RELEVANCE TO CLINICAL PRACTICE: Results suggest that nurses' perception of patient involvement in the ICU depends on the patient's level of consciousness. Patient involvement may be possible even when the patient is unconscious but it takes a more physical approach. It is essential that the power inequality in the nurse-patient relationship must be expressed if patient involvement in the ICU is to take place.

Auditory stimulation in-phase with slow oscillations to enhance overnight memory consolidation in patients with schizophrenia?

Sleep-dependent memory consolidation is disturbed in patients with schizophrenia, who furthermore show reductions in sleep spindles and probably also in delta power during sleep. The memory dysfunction in these patients is one of the strongest markers for worse long-term functional outcome. However, therapeutic interventions to normalise memory functions, e.g., with medication, still do not exist. Against this backdrop, we investigated to what extent a non-invasive approach enhancing sleep with real-time auditory stimulation in-phase with slow oscillations might affect overnight memory consolidation in patients with schizophrenia. To this end, we examined 18 patients with stably medicated schizophrenia in a double-blinded sham-controlled design. Memory performance was assessed by a verbal (word list) and a non-verbal (complex figure) declarative memory task. In comparison to a sham condition without auditory stimuli, we found that in patients with schizophrenia, auditory stimulation evokes an electrophysiological response similar to that in healthy participants leading to an increase in slow wave and temporally coupled sleep spindle activity during stimulation. Despite this finding, patients did not show any beneficial effect on the overnight change in memory performance by stimulation. Although the stimulation in our study did not improve the patient's memory, the electrophysiological response gives hope that auditory stimulation could enable us to provide better treatment for sleep-related detriments in these patients in the future.

Childhood hearing loss: Impact on parents and family life.

BACKGROUND: Studies investigating the impact of having a child with hearing loss on the lives of parents and families have shown divergent results. Where some studies have reported that childhood hearing loss is associated with parental mental health problems, such as depression and stress, other studies report no impact on parental mental health and/or wellbeing. OBJECTIVE: The aim of this study was to examine the association between child-related variables-degree of hearing loss, additional disabilities, sign language abilities, cochlear implants (CI), externalizing and internalizing emotional and behavioral difficulties measured by the Strength and Difficulties Questionnaire (SDQ)-and parent-related variables-parents living together, parents' mental health, spouse activities without children, and parents' experience of the child as being a burden for the family. METHOD: Data of 257 parents of children with hearing loss from a national survey were included. RESULTS: Only 18% of the children with hearing loss did not live with both parents, a figure significantly lower than that of the general population. The child variables of degree of hearing loss, having a CI or not, and sign language ability were not significantly associated with any of the parent variables investigated. The child having a disability in addition to hearing loss was found to be significantly associated with the frequency of spouses engaging in activities without children and reports that the child was a burden for the family. Both higher externalizing and internalizing scores on the SDQ were significantly associated with parental mental health problems, frequency of spouse activities without children, and the degree to which the child's difficulties were experienced as a burden for the family. CONCLUSION: Children's hearing loss, per se, was found not to be significantly related to several key parent and family variables. However, children having additional disabilities and behavioral and emotional difficulties were significant with parent and family variables. This study thus underlines the need for further studies concerning relationships among factors related to childhood hearing loss and various family factors in order to better understand their impact on child development and family life.

Lowered threshold energy for femtosecond laser induced optical breakdown in a water based eye model by aberration correction with adaptive optics.

In femtosecond laser ophthalmic surgery tissue dissection is achieved by photodisruption based on laser induced optical breakdown. In order to minimize collateral damage to the eye laser surgery systems should be optimized towards the lowest possible energy threshold for photodisruption. However, optical aberrations of the eye and the laser system distort the irradiance distribution from an ideal profile which causes a rise in breakdown threshold energy even if great care is taken to minimize the aberrations of the system during design and alignment. In this study we used a water chamber with an achromatic focusing lens and a scattering sample as eye model and determined breakdown threshold in single pulse plasma transmission loss measurements. Due to aberrations, the precise lower limit for breakdown threshold irradiance in water is still unknown. Here we show that the threshold energy can be substantially reduced when using adaptive optics to improve the irradiance distribution by spatial beam shaping. We found that for initial aberrations with a root-mean-square wave front error of only one third of the wavelength the threshold energy can still be reduced by a factor of three if the aberrations are corrected to the diffraction limit by adaptive optics. The transmitted pulse energy is reduced by 17% at twice the threshold. Furthermore, the gas bubble motions after breakdown for pulse trains at 5 kilohertz repetition rate show a more transverse direction in the corrected case compared to the more spherical distribution without correction. Our results demonstrate how both applied and transmitted pulse energy could be reduced during ophthalmic surgery when correcting for aberrations. As a consequence, the risk of retinal damage by transmitted energy and the extent of collateral damage to the focal volume could be minimized accordingly when using adaptive optics in fs-laser surgery.

Animal production for efficient phosphate utilization: from optimized feed to high efficiency livestock.

Phosphorus (P) is an essential nutrient for livestock but its efficiency of utilization is below 40%, contributing to environmental issues. In this review, we summarize recent approaches to optimize P availability in livestock diets and improve its utilization efficiency. Phase feeding could potentially reduce P excretion by 20%. Addition of phytase enzymes to diets increased P availability from 42 to 95%. Low phytate transgenic plants and transgenic animals increased P availability by 14% and 52-99%, respectively. In practice, a combination of phase feeding and enzymes has the highest potential for P reduction but legislation and ethics implications will prevent using transgenic animals in the short term. Functional and nutritional genomics may provide tools to improve efficiency in the future.

Telescopic crowns: extra-oral and intra-oral retention force measurement--in vitro/in vivo correlation.

OBJECTIVE: This study deals with the determination of the retentive forces of telescopic crowns measured extra- and intra-orally and the correlation of these values. BACKGROUND: The telescopic denture is a well-documented solution for prosthetic rehabilitation for a partially edentulous jaw. Acceptable retention forces are needed to avoid inadvertent removal of the denture during movement of the jaws. Recent literature suggests 3-7 N per attachment to be acceptable. These values are only supported by in vitro studies. In vivo data are scarce, and a correlation of the in vitro and in vivo values is lacking. MATERIAL AND METHODS: Twenty-five combined fixed-removable prostheses with a total of 72 double crowns were used for extra-oral retention force measurement prior to cementation (in vitro). The intra-oral measurement was performed at 72 defined measuring points of the dentures 4-6 weeks after prosthetic rehabilitation (in vivo). A specifically designed measuring device was used. RESULTS: The rank correlation showed that the in vitro and in vivo values correlate with each other (Spearman's ρ = 0.5052). Additionally, it was found that the median values measured before (1.97N) insertion of the dentures were significantly lower than after (4.70N) insertion (Mann-Whitney test, p ≤ 0.0001). CONCLUSION: The retention forces measured before and after insertion of the denture correlate with each other although their dimension is significantly higher after insertion. The reason for this behaviour might be some tilting during removal. Nevertheless, the correlation allows a prediction of the clinically relevant forces by a measurement of the extra-orally measured retentive values.

Clinical retention force development of double crowns.

This study deals with the development of the retentive forces of double crowns intraorally measured. Twenty-five combined fixed-removable prostheses with a total of 84 double crowns were included in the study. The intraoral measurement was performed at 72 defined measuring points directly adjacent to the double crowns of the dentures. The measurement was performed 4-6 weeks (baseline), 6 months (recall 1), and 18 months (recall 2) after the insertion of the restoration. A specifically designed measuring device was used. The median values for the single measuring points reached 4.705 N at the baseline, 5.190 N after 6 months, and 3.740 N after 18 months. The measured values were analyzed according to differences between the median retention forces at the three defined points in time. The statistical analysis of the median values showed no statistical difference for the retention force change after 6 months but for the decrease until the second recall (Mann-Whitney test). The retention force per denture was calculated by a summation of the single measuring points. At the baseline, 12.9 N was reached. The forces did only decrease slightly and were not statistically significant. The results indicate that retention force values of double crowns, measured intraorally at the patient, do not relevantly change clinically within the first 1.5 years. Within the limitations of this study, it can be stated that wear does not influence the retentive forces of double crowns within the first 18 months. After this period the retention force should be still sufficient for denture retention.

The prevalence of diabetic retinopathy in patients with screen-detected type 2 diabetes in Denmark: the ADDITION study.

BACKGROUND: The prevalence of type 2 diabetes is increasing, but the exact prevalence of the disease and its accompanying late complications are unknown. In the Anglo-Danish-Dutch study of Intensive Treatment in People with Screen-detected Diabetes in Primary Care (ADDITION study), patients with hitherto undiagnosed type 2 diabetes are identified using a stepwise screening strategy in selected general practices. This article reports the occurrence of diabetic retinopathy in this population. METHODS: In Arhus and Copenhagen counties, a total of 12,708 of the persons invited by mail were screened for diabetes mellitus. Consequently, 763 persons with type 2 diabetes were identified; 670 of these (335 from each of the two centres) underwent a general physical examination (including measurement of blood pressure and HbA1c) and an ophthalmological examination (including measurement of visual acuity and fundus photography). Retinopathy was graded from the photographs by counting all retinopathy lesions. RESULTS: Forty-five (6.8%) of the examined patients had any retinopathy, of which the majority was minimal. No patients had severe non-proliferative or proliferative diabetic retinopathy. There was no significant difference between age, sex and visual acuity among patients with and without retinopathy. However, the patients with retinopathy had significantly higher HbA1c and systolic and diastolic blood pressure than the patients without retinopathy. CONCLUSION: Patients with screen-detected diabetes have a low prevalence of diabetic retinopathy and no vision-threatening lesions. Screening for diabetic retinopathy should be focused on those patients who have already been diagnosed with type 2 diabetes during routine clinical practice.

Long-term experimental warming, shading and nutrient addition affect the concentration of phenolic compounds in arctic-alpine deciduous and evergreen dwarf shrubs.

Environmental changes are likely to alter the chemical composition of plant tissues, including content and concentrations of secondary compounds, and thereby affect the food sources of herbivores. After 10 years of experimental increase of temperature, nutrient levels and light attenuation in a sub-arctic, alpine ecosystem, we investigated the effects on carbon based secondary compounds (CBSC) and nitrogen in one dominant deciduous dwarf shrub, Salix herbacea x polaris and two dominant evergreen dwarf shrubs, Cassiope tetragona and Vaccinium vitis-idaea throughout one growing season. The main aims were to compare the seasonal course and treatment effects on CBSC among the species, life forms and leaf cohorts and to examine whether the responses in different CBSC were consistent across compounds. The changes in leaf chemistry both during the season and in response to the treatments were higher in S. herbacea x polaris than in the corresponding current year's leaf cohort of the evergreen C. tetragona. The changes were also much higher than in the 1-year-old leaves of the two evergreens probably due to differences in dilution and turnover of CBSC in growing and mature leaves paired with different rates of allocation. Most low molecular weight phenolics in the current year's leaves decreased in all treatments. Condensed tannins and the tannin-to-N ratio, however, either increased or decreased, and the strength and even direction of the responses varied among the species and leaf cohorts, supporting views of influential factors additional to resource-based or developmental controls, as e.g. species specific or genetic controls of CBSC. The results indicate that there is no common response to environmental changes across species and substances. However, the pronounced treatment responses imply that the quality of the herbivore forage is likely to be strongly affected in a changing arctic environment, although both the direction and strength of the responses will be different among plant species, tissue types and substances.

Model simulation of the patient flow through a screening centre for diabetic retinopathy.

PURPOSE: To construct a quantitative, flexible and simplified mathematical model of the patient flow through the Eye Clinic at the Steno Diabetes Centre (SDC) in order to enable rational dimensioning and assess the effects of modifications. METHODS: Patient data were drawn from the Eye Care database at the SDC. A simple patient flow model was constructed, allowing simultaneous adjustments of all variables, and the model was tested. Two scenarios were simulated: (1) adjusting the algorithm that assigns the follow-up intervals, and (2) increasing the population size to include all patients with diabetes in Copenhagen County. RESULTS: The model can describe the patient flow under steady state conditions, but is less precise in predicting transient changes with the present set-up. Accordingly all simulations were run for a substantial number of iterations. The two scenarios illustrate the usefulness of the model by calculating the required photographic examination capacity for the specific population, thereby allowing better estimations of future dimensioning of the organization. CONCLUSION: The study presents a patient flow model that can be used to illustrate the effects of proposed changes prior to their implementation, specifically with respect to the capacity of the system.

Screening for diabetic retinopathy using a digital non-mydriatic camera compared with standard 35-mm stereo colour transparencies.

PURPOSE: To investigate the use of a digital non-mydriatic camera for determining the ETDRS clinical level of diabetic retinopathy, and to evaluate its use in a screening setting to appropriately determine the need for referral to an ophthalmologist (ETDRS level > or = 35). METHODS: A total of 83 patients with diabetes were photographed with and without pharmacological pupil dilation at an ophthalmology department using a digital non-mydriatic camera, obtaining two sets of five non-stereoscopic, 45 degree field images of each eye. ETDRS seven standard field, 35-mm stereoscopic colour fundus photographs were also obtained. A subgroup of 59 patients was photographed at an optician's shop using the digital non-mydriatic camera without pupil dilation. RESULTS: There was substantial agreement between the clinical level of diabetic retinopathy assessed from the 35-mm photographs and the digital images: the ophthalmology department (kappa = 0.76) with pupil dilation and (kappa = 0.66) without pupil dilation, respectively, and at the optician's (kappa = 0.60 without pupil dilation). With respect to the need for referral to an ophthalmologist, there was almost perfect agreement in the ophthalmology department (kappa = 0.88) with pupil dilation and (kappa = 0.84) without pupil dilation, respectively, and those taken at the optician's (kappa = 0.87 without pupil dilation). CONCLUSION: A digital non-mydriatic camera may be used in a screening situation to appropriately determine the need for referral to an ophthalmologist (ETDRS level > or = 35).

Diabetic retinopathy screening using digital non-mydriatic fundus photography and automated image analysis.

PURPOSE: To investigate the use of automated image analysis for the detection of diabetic retinopathy (DR) in fundus photographs captured with and without pharmacological pupil dilation using a digital non-mydriatic camera. METHODS: A total of 83 patients (165 eyes) with type 1 or type 2 diabetes, representing the full spectrum of DR, were photographed with and without pharmacological pupil dilation using a digital non-mydriatic camera. Two sets of five overlapping, non-stereoscopic, 45-degree field images of each eye were obtained. All images were graded in a masked fashion by two readers according to ETDRS standards and disagreements were settled by an independent adjudicator. Automated detection of red lesions as well as image quality control was made: detection of a single red lesion or insufficient image quality was categorized as possible DR. RESULTS: At patient level, the automated red lesion detection and image quality control combined demonstrated a sensitivity of 89.9% and specificity of 85.7% in detecting DR when used on images captured without pupil dilation, and a sensitivity of 97.0% and specificity of 75.0% when used on images captured with pupil dilation. For moderate non-proliferative or more severe DR the sensitivity was 100% for images captured both with and without pupil dilation. CONCLUSION: Our results demonstrate that the described automated image analysis system, which detects the presence or absence of DR, can be used as a first-step screening tool in DR screening with considerable effectiveness.

Screening for diabetic retinopathy in Denmark: the current status.

PURPOSE: To investigate the current status of screening for diabetic retinopathy in Denmark, focussing on organization, methods of screening and regional differences. METHODS: A questionnaire was sent out in 2002 to 14 departments of ophthalmology and one ophthalmology practice, covering all 15 counties in Denmark. RESULTS: Six counties reported having systematic screening, defined as organized screening, including a database; three reported having plans for systematic screening; two reported having undetermined plans for systematic screening and four reported having no plans for systematic screening. In counties with systematic screening, both the organization and the method of screening varied. CONCLUSION: Approximately 43% of Danish patients with diabetes currently live in a county without systematic screening for diabetic retinopathy. Should all counties contemplating systematic screening implement their plans, this proportion will be reduced to approximately 17%.