Finnish and Swedish prehospital emergency care providers' knowledge and attitudes towards pressure ulcer prevention.

BACKGROUND: Despite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs. METHODS: A survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used. RESULTS: A total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%). CONCLUSIONS: Prehospital emergency care providers don't see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.

Assessing the discharge instructing in the emergency department: Patient perspective.

OBJECTIVE: The objective of the study is to assess how well the emergency department (ED) personnel succeed in instructing the patient at discharge. METHODS: In November and December 2016 at Peijas Hospital ED, Finland, a structured questionnaire was conducted during a phone interview on patients the day after discharge. RESULTS: A total of 132 patients interviewed. Ninety percent had received discharge instructions from the ED staff, most of them (75%) about medication. Almost half of the patients (45%) were satisfied with the communication at discharge, those not satisfied (47%) felt that the staff did not know enough of their background to give discharge instructions. Of the patients, 20% thought that they did not have the opportunity to ask questions during the guidance session, and 41% thought that the session was too short and restricted. Some patients (20%) felt that the instructions were ambiguous, but 63% (83/132) felt they were able to follow them well or very well. CONCLUSION: The pace of care in the ED is fast and duration of the stay is short. The patients must be able to take responsibility of their self-care. Failure to follow medical discharge instructions could lead to non-compliance. Attention should be paid to enhancing the quality of discharge instructing and the instructions provided by the ED personnel, as recurring visits and inquiry calls add to the ED workload.

Biodegradation of inorganic drug delivery systems in subcutaneous conditions.

Despite extensive efforts to develop delivery systems for oral administration, subcutaneous (s.c.) injection remains the most common way to administer peptide drugs. To limit the number of frequent injections, sustained release systems that are easy to produce, suitable for various drugs, safe and biodegradable are urgently needed. Porous silicon (PSi) has been recognized to be one of the most promising materials for s.c. peptide delivery, but its biodegradation in s.c. tissue has not been studied in vivo, despite extensive in vitro research. In the present study, differently modified PSi microparticles were injected s.c. in mice, after which the morphology of the particles was thoroughly studied with transmission electron microscopy, micro-computed tomography and X-ray diffraction. Furthermore, histopathology of the s.c. tissue was analyzed to evaluate biocompatibility. To the best of our knowledge, this is the first systematic study which reveals the degradation behavior of various PSi materials in vivo. The PSi surface chemistry significantly affected the biodegradation rate of the s.c. injected microparticles. The most hydrophobic PSi microparticles with hydrocarbonized surface showed the lowest biodegradation rate while the hydrophilic microparticles, with oxide surface, degraded the fastest. The results from different empirical methods complemented each other to deduce the biodegradation mechanism of the inorganic delivery system, providing useful information for future development of s.c. carriers.

Thermal suit in preventing unintentional intraoperative hypothermia during general anaesthesia: a randomized controlled trial.

BACKGROUND: Unintentional perioperative hypothermia causes serious adverse effects to surgical patients. Thermal suit (T-Balance® ) is an option for passive warming perioperatively. We hypothesized that the thermal suit will not maintain normothermia more efficiently than conventional cotton clothes when also other preventive procedures against unintentional hypothermia are used. METHODS: One hundred patients were recruited to this prospective, randomized trial. They were allocated to the Thermal Suit group or a Control group wearing conventional hospital cotton clothes. All patients received our institution's standard treatment against unintentional hypothermia including a warming mattress, a forced-air upper body warming blanket and a warming device for intravenous fluids. Eardrum temperature was measured pre-operatively. In the operating room and post-anaesthesia care unit temperatures were measured from four locations: oesophagus, left axilla, dorsal surface of the left middle finger and dorsum of the left foot. The primary outcome measure was temperature change during robotic-assisted laparoscopic radical prostatectomy. RESULTS: The temperatures of 96 patients were analysed. There was no difference in mean core temperatures, axillary temperatures or skin temperatures on the finger between the groups. Only foot dorsum temperatures were significantly lower in the Thermal Suit group. Intraoperative temperature changes were similar in both groups. In the post-anaesthesia care unit temperature changes were minimal and they did not differ between the groups. CONCLUSION: Provided that standard preventive procedures in maintaining normothermia are effective the thermal suit does not provide any additional benefit over conventional cotton clothes during robotic-assisted laparoscopic radical prostatectomy.

The effects of interprofessional education - Self-reported professional competence among prehospital emergency care nursing students on the point of graduation - A cross-sectional study.

The aim of the study was to investigate whether interprofessional education (IPE) and interprofessional collaboration (IPC) during the educational program had an impact on prehospital emergency care nurses' (PECN) self-reported competence towards the end of the study program. A cross-sectional study using the Nurse Professional Competence (NPC) Scale was conducted. A comparison was made between PECN students from Finland who experienced IPE and IPC in the clinical setting, and PECN students from Sweden with no IPE and a low level of IPC. Forty-one students participated (Finnish n=19, Swedish n=22). The self-reported competence was higher among the Swedish students. A statistically significant difference was found in one competence area; legislation in nursing and safety planning (p<0.01). The Finnish students scored significantly higher on items related to interprofessional teamwork. Both the Swedish and Finnish students' self-reported professional competence was relatively low according to the NPC Scale. Increasing IPC and IPE in combination with offering a higher academic degree may be an option when developing the ambulance service and the study program for PECNs.

Trainers' Attitudes towards Cardiopulmonary Resuscitation, Current Care Guidelines, and Training.

Objectives. Studies have shown that healthcare personnel hesitate to perform defibrillation due to individual or organisational attitudes. We aimed to assess trainers' attitudes towards cardiopulmonary resuscitation and defibrillation (CPR-D), Current Care Guidelines, and associated training. Methods. A questionnaire was distributed to CPR trainers attending seminars in Finland (N = 185) focusing on the updated national Current Care Guidelines 2011. The questions were answered using Likert scale (1 = totally disagree, 7 = totally agree). Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Seven scales were constructed (Hesitation, Nurse's Role, Nontechnical Skill, Usefulness, Restrictions, Personal, and Organisation). Cronbach's alphas were 0.92-0.51. Statistics were Student's t-test, ANOVA, stepwise regression analysis, and Pearson Correlation. Results. The questionnaire was returned by 124/185, 67% CPR trainers, of whom two-thirds felt that their undergraduate training in CPR-D had not been adequate. Satisfaction with undergraduate defibrillation training correlated with the Nontechnical Skills scale (p < 0.01). Participants scoring high on Hesitation scale (p < 0.01) were less confident about their Nurse's Role (p < 0.01) and Nontechnical Skills (p < 0.01). Conclusion. Quality of undergraduate education affects the work of CPR trainers and some feel uncertain of defibrillation. The train-the-trainers courses and undergraduate medical education should focus more on practical scenarios with defibrillators and nontechnical skills.

Diagnostic and Prognostic Value of Serum Interleukin-6 in Colorectal Cancer.

The application of serum interleukin-6 (IL-6) in the diagnosis and prognosis of colorectal cancer (CRC) has been evaluated in many studies, whereas the results were contradictive.The aim of this study was to systematically evaluate this issue.An original study was conducted to explore the diagnostic value of serum IL-6 in CRC. Pubmed, Embase, and Cochrane library databases were searched for eligible studies.For diagnostic meta-analysis, aggregate data (AD) and individual participant data (IPD) meta-analyses were both adopted. The sensitivity and specificity were pooled and a summary receiver-operating characteristic (ROC) curve was constructed. For prognostic meta-analysis, study-specific hazard ratios (HRs) of IL-6 for survival were summarized. Secondary analysis of survival data was performed to synthesize the Kaplan-Meier curves.Total 17 studies (including our study) were included in this meta-analysis. The pooled sensitivity, specificity, and area under curve (AUC) of serum IL-6 were 0.72 (95% CI: 0.46-0.88), 0.74 (95% CI: 0.56-0.86), and 0.79 (95% CI: 0.75-0.82) in CRC diagnosis, respectively. Further, IPD meta-analysis strengthened the diagnostic value of serum IL-6 (the AUC, sensitivity, and specificity were 0.794, 0.606, and 0.839, respectively). For prognostic analysis, the high serum level of IL-6 was inversely associated with overall survival (OS) (pooled HR = 1.76, 95% CI: 1.42-2.19, P < 0.001) and disease-free survival (DFS) (pooled HR = 2.97, 95% CI: 1.76-5.01, P < 0.001). The synthesized Kaplan-Meier curves indicated that CRC patients with higher serum IL-6 level had a worse OS (P = 0.0027) and DFS (P < 0.001), which further support the prognostic value of serum IL-6 in CRC patients.The present study confirmed that serum IL-6 may be a potential biomarker for CRC diagnosis, and the high serum IL-6 level was associated with poor prognosis for both CRC overall survival and disease-free survival. The study has been registered in an international registry of systematic reviews PROSPERO (CRD42013006485).

Serum endostatin levels are elevated in colorectal cancer and correlate with invasion and systemic inflammatory markers.

BACKGROUND: Endostatin, a fragment of collagen XVIII, is an endogenous angiogenesis inhibitor with anti-tumour functions. However, elevated circulating endostatin concentrations have been found in several human cancers including colorectal cancer (CRC). METHODS: Serum endostatin levels were measured by enzyme-linked immunoassay from a series of 143 patients with CRC and from 84 controls, and correlated with detailed clinicopathological features of CRC, serum leukocyte differential count and C-reactive protein (CRP) levels. RESULTS: Patients with CRC had higher serum endostatin levels than the controls (P=0.005), and high levels associated with age, tumour invasion through the muscularis propria and poor differentiation, but not with metastases. Endostatin levels showed a positive correlation with the markers of systemic inflammatory response and a negative correlation with the densities of tumour-infiltrating mast cells and dendritic cells. Collagen XVIII was expressed in tumour stroma most strikingly in blood vessels and capillaries, and in the muscle layer of the bowel wall. CONCLUSIONS: Elevated endostatin levels in CRC correlate with systemic inflammation and invasion through the muscularis propria. Increased endostatin level may be a result of invasion-related cleavage of collagen XVIII expressed in the bowel wall. The negative correlations between serum endostatin and intratumoural mast cells and immature dendritic cells may reflect angiogenesis inhibition by endostatin.

Detailed analysis of inflammatory cell infiltration in colorectal cancer.

BACKGROUND: Higher-grade inflammatory infiltrate is a promising marker for better prognosis in colorectal cancer (CRC). However, the knowledge on the interrelationships between different inflammatory cells and classifications is fragmentary. METHODS: We analysed the densities of eight types of inflammatory cells in a prospectively recruited group of 117 CRC patients and determined their interrelationships and contributions to Klintrup-Mäkinen (K-M) score of overall peritumoural inflammation. We characterised the inflammatory infiltrate in relation to stage and recurrences in 24-month follow-up. RESULTS: There were high positive correlations between the inflammatory cell densities, with the exception of mast cells and CD1a+ immature dendritic cells. High K-M score associated with high peri- and intratumoural densities of CD3+, CD8+, CD68+, CD83+, and FoxP3+ cells and neutrophils. Advanced stage associated with low K-M score, as well as low CD3+, CD8+, CD83+, and FoxP3+ cell counts, of which low K-M score, low CD3(+) T-cell count, and low FoxP3+ T-cell count were linked to higher recurrence rate. CONCLUSION: The density of CRC inflammatory infiltrate declines as stage advances. Especially, low K-M score and low T-cell counts predict higher recurrence rate. The high positive correlations between the individual inflammatory markers support the value of overall inflammatory reaction scoring.

Fluorescent probes as a tool for cell population tracking in spontaneously active neural networks derived from human pluripotent stem cells.

Applications such as 3D cultures and tissue modelling require cell tracking with non-invasive methods. In this work, the suitability of two fluorescent probes, CellTracker, CT, and long chain carbocyanine dye, DiD, was investigated for long-term culturing of labeled human pluripotent stem cell-derived neural cells. We found that these dyes did not affect the cell viability. However, proliferation was decreased in DiD labeled cell population. With both dyes the labeling was stable up to 4 weeks. CT and DiD labeled cells could be co-cultured and, importantly, these mixed populations had their normal ability to form spontaneous electrical network activity. In conclusion, human neural cells can be successfully labeled with these two fluorescent probes without significantly affecting the cell characteristics. These labeled cells could be utilized further in e.g. building controlled neuronal networks for neurotoxicity screening platforms, combining cells with biomaterials for 3D studies, and graft development.

Stage-dependent alterations of the serum cytokine pattern in colorectal carcinoma.

BACKGROUND: Inflammation contributes to the pathogenesis of colorectal cancer (CRC), and cytokine levels are altered during colorectal carcinogenesis. METHODS: The serum levels of 13 cytokines and their relation to clinical and pathological parameters, and systemic inflammatory response (mGPS, CRP and neutrophil-lymphocyte ratio), were analysed from a prospective series of 148 CRC patients and 86 healthy age- and sex-matched controls. RESULTS: CRC patients had higher serum platelet-derived growth factor, interleukin (IL)-6, IL-7, and IL-8 levels and lower monocyte chemotactic protein-1 (MCP-1) levels than the controls. A logistic regression model for discriminating the patients from the controls - including the five most predictive cytokines (high IL-8, high IL-6, low MCP-1, low IL-1ra, and low IP-10) - yielded an area under curve value of 0.890 in receiver operating characteristics analysis. Serum cytokines showed distinct correlation with other markers of systemic inflammatory response, and advanced CRCs were associated with higher levels of IL-8, IL-1ra, and IL-6. A metastasised disease was accompanied by an orientation towards Th2 cytokine milieu. CONCLUSION: CRC is associated with extensive alterations in serum cytokine environment, highlighting the importance of studying relative cytokine level alterations. Serum cytokine profile shows promise in separating CRC patients from healthy controls but its clinical value is yet to be confirmed.

The effect of humidity on sensitivity of amine detection in ion mobility spectrometry.

Vaporized water molecules are unavoidably present in every ion mobility spectrometry (IMS) measurement. In general, this humidity is seen in positive mode IMS-spectra as protonated water clusters producing reactant ions. Clusters containing water molecules are also abundant among ions generated by an analyte. In this paper the influence of humidity on IMS-spectra was systematically investigated and determined by measuring different concentrations of a selected amine at various levels of humidity. The selected amine, trimethylamine (TMA), was chosen as the model analyte due to its atmospheric importance. During the measurements, surplus water vapor was introduced into the drift section inside the IMS instrument; the concentrations of both amine and water were adjusted by controlling the gas flows. The simultaneous presence of water vapor and analyte at various predefined concentrations revealed the sensitivity of the IMS-technique to water and the effect of moisture on the ion mobility distribution. The results indicated that the existence, positions and shapes of the peaks are strongly dependent on the amount of moisture. However, the sensitivity of detection is weakly dependent on humidity if this detection is based on monomer ion peak or the sum of peaks generated by the analyte, In addition, the main principles of the adjustment of sample and water concentrations are presented here.

Aryl hydrocarbon receptor interacting protein mutations seem not to associate with familial non-medullary thyroid cancer.

BACKGROUND: Over 95% of all thyroid malignancies are non-medullary thyroid carcinomas (NMTC). Familial NMTC are more aggressive and mortality is higher as compared with sporadic carcinomas. Known genetic factors do not explain all familial NMTC. Recently, thyroid disorders have been observed in families with germline mutations in aryl hydrocarbon receptor interacting protein (AIP) but, due to frequent occurrence of these conditions in the population, the significance of this co-occurrence is not clear. AIM, SUBJECTS AND METHODS: To examine whether AIP is involved in familial NMTC, we performed AIP mutation screening in 93 familial NMTC cases. In addition, the AIP status was studied in one follicular thyroid adenoma patient with a known AIP mutation from an additional cohort. RESULTS: No potentially pathogenic changes were identified, but two likely rare polymorphisms were detected. AIP mutation-positive patient's follicular thyroid adenoma showed no loss of heterozygosity or lack of immunohistochemical AIP staining. CONCLUSION: Our study indicates that germline AIP mutations are rare or do not exist in familial NMTC.

Nurses' attitudes towards resuscitation and national resuscitation guidelines--nurses hesitate to start CPR-D.

UNLABELLED: National resuscitation guidelines were published in Finland in 2002 and updated in 2006. The purpose of this study was to analyse the effect of cardiopulmonary resuscitation (CPR) education on attitudes towards defibrillation during arrests (CPR-D) and the guidelines. METHODS: In 2003 (before CPR-D education) and in 2007 (after the education), 48-item questionnaires (using a 7-point Likert scale: 1=totally disagree, 7=totally agree) were sent to nurses in a secondary hospital. Factor loadings were applied using maximum likelihood factor analyses with a varimax rotation. Five scales were built from the items of the questionnaire: attitudes towards CPR-D, positive attitudes, negative attitudes towards guidelines, implementation and nurses' role. RESULTS: A total of 297 and 199 responded in 2003 and 2007, respectively. Education increased positive attitudes towards CPR-D (scale mean: 4.40 vs. 3.61, 95% confidence interval (CI): 3.9-4.2, P<0.001). Nevertheless, 27% of nurses hesitated to perform defibrillation because of fear of injuring patient and 64% because of anxiety. After education, negative attitudes towards guidelines increased (scale mean 2.94 vs. 3.92, 95% CI: 3.2-3.6, P<0.001) and nurses were more unsure about their role than before education (scale mean: 4.84 vs. 3.42, 95% CI: 4.1-4.4, P<0.001). CONCLUSIONS: Intensive education increased self-confidence regarding CPR-D skills but did not reduce anxiety. CPR-D education should include a focus on reducing anxiety, and negative attitudes within organisations need to be explored.

Introducing new vaccines in the poorest countries: what did we learn from the GAVI experience with financial sustainability?

This paper reviews the experience of the Global Alliance for Vaccines and Immunization (GAVI) in introducing hepatitis B and Haemophilus influenzae type b vaccines in the poorest countries, and explores how financing for immunization has changed since GAVI Fund resources were made available during its first wave of support between 2000 and 2006. The analysis of Financial Sustainability Plans in 50 countries allowed for some of the original funding assumptions of the GAVI approach to be tested against the realities in a wide set of countries, and to highlight implications for future immunization efforts. While the initial GAVI experience with financial sustainability has proved successful through the development of plans, and many countries have been able to both introduce new vaccines and mobilize additional financing for immunization, for future GAVI supported vaccine introduction, some country co-financing of these will be needed upfront for the approach to be more sustainable.

Local staging of rectal cancer using the black lumen magnetic resonance imaging technique.

BACKGROUND AND AIMS: The treatment of rectal cancer is comprised of surgery and possible adjuvant therapy depending on the stage of the tumour. This prospective study evaluates the accuracy of magnetic resonance imaging (MRI) in the preoperative staging of rectal cancer using an endorectal and intravenous contrast. MATERIALS AND METHODS: 37 consecutive patients with rectal cancer were imaged using a mixture of ferumoxsil and methylcellulose endorectally, and a gadolinium contrast intravenously. 33 tumours were resected and 4 tumours were considered unresectable during operation. The images were reviewed for local staging of the tumours. A tumour confined to the rectal wall was classified as a negative finding and a tumour invading through muscularis propria as a positive finding. The results were correlated with the histopathologic t stage (n = 33), or the clinical status (n = 4). RESULTS AND CONCLUSIONS: of 37 cases, 20 (51 %) were true positive, and 11 (28%) were true negative. There were 3 false negative and 3 false positive cases. The sensitivity was 87%, specificity 79%, and diagnostic accuracy 84%. for the non-contrast images the figures were 78%, 79% and 78%, respectively. We consider black lumen magnetic resonance imaging to be a useful method for preoperative local staging of rectal cancer.

No evidence of somatic aryl hydrocarbon receptor interacting protein mutations in sporadic endocrine neoplasia.

Germline mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene were recently observed in patients with pituitary adenoma predisposition (PAP). Though AIP mutation-positive individuals with prolactin-, mixed growth hormone/prolactin-, and ACTH-producing pituitary adenomas as well as non-secreting pituitary adenomas have been reported, most mutation-positive patients have had growth hormone-producing adenomas diagnosed at relatively young age. Pituitary adenomas are also component tumors of some familial endocrine neoplasia syndromes such as multiple endocrine neoplasia type 1 (MEN1) and Carney complex (CNC). Genes underlying MEN1 and CNC are rarely mutated in sporadic pituitary adenomas, but more often in other lesions contributing to these two syndromes. Thus far, the occurrence of somatic AIP mutations has not been studied in endocrine tumors other than pituitary adenomas. Here, we have analyzed 32 pituitary adenomas and 79 other tumors of the endocrine system for somatic AIP mutations by direct sequencing. No somatic mutations were identified. However, two out of nine patients with prolactin-producing adenoma were shown to harbor a Finnish founder mutation (Q14X) with a complete loss of the wild-type allele in the tumors. These results are in agreement with previous studies in that prolactin-producing adenomas are component tumors in PAP. The data also support the previous finding that somatic AIP mutations are not common in pituitary adenomas and suggest that such mutations are rare in other endocrine tumors as well.

Colorectal serrated adenocarcinoma.

Colorectal cancer (CRC) ranks among the three most common cancers in terms of both cancer incidence and cancer-related deaths in most Western countries. Serrated adenocarcinoma is a recently described, distinct variant of CRC, accounting for about 7.5% of all CRCs and up to 17.5% of most proximal CRCs. It has been postulated that about 10-15% of sporadic CRCs would have their origin in serrated polyps that harbour a significant malignant potential. These lesions include hyperplastic-type aberrant crypt foci, hyperplastic polyps, sessile serrated adenomas, admixed polyps and serrated adenomas, and constitute the so-called 'serrated pathway', which is distinct from both the conventional adenoma-carcinoma pathway and the mutator pathway of hereditary non-polyposis CRC and is characterized by early involvement of oncogenic BRAF mutations, excess CpG island methylation (CIM) and subsequent low- or high-level DNA microsatellite instability (MSI). Methylation of hMLH1 is likely to explain the increased frequency of high-level MSI (16%) and methylation of MGMT is postulated to explain the low-level MSI (29%) in serrated adenocarcinomas. Reproducible histopathological criteria for serrated adenocarcinoma have recently been established and they have been qualified by DNA expression analysis for 7928 genes, showing clustering of serrated adenocarcinomas into a molecular entity apart from conventional adenocarcinoma, and representing with distinct down-regulation of EPHB2, PTCH and up-regulation of HIF1alpha.