Supporting first-time parents in their homes: an informal setting enabling interprofessional collaboration.

BACKGROUND: Home visiting programmes aiming to support parents and promote more equal health amongst young children have grown in Sweden and in other countries. These programmes involve interprofessional teams. Teamwork in interprofessional contexts often requires setting boundaries, but professionals' boundary work in the home setting is unexplored. Therefore, this article focuses on interprofessional teams comprising child healthcare nurses, midwives, social workers, and dental hygienists in a home visiting programme for first-time parents in Sweden; it aims to explore how the professionals performed boundary work that enabled collaboration and to investigate important contextual conditions for this kind of boundary work. METHODS: The data were drawn from semi-structured interviews with twelve professionals from the four different disciplines. Content analysis was used to explore their boundary work. RESULTS: The findings show that the professionals performed three forms of collaborative boundary work. They maintained boundaries by clarifying their distinct roles and expertise. However, the differences were viewed as complementary, and the professionals worked together humbly to complement each other's knowledge and perspectives. Lastly, they tended to drop perceptions of prestige and blurred the boundaries to accommodate their overlapping knowledge. Important conditions for the success of collaborative boundary work were meetings prior to the home visits, the opportunities for discussion and reflection after the home visits, and the informal character of the home setting. Consequently, the professionals were able to jointly contribute to a holistic view of the visited families, which increased the possibilities to meet these families' needs. CONCLUSIONS: This study contributes knowledge on boundary work in interprofessional collaborations in the home setting. The informal character of the home setting seemed to facilitate collaboration and contributed to creating informal professional roles. The findings suggest that having interprofessional teams in the home setting enabled collaboration as well as reinforced support for first-time parents, which emphasizes the merit of home visit programmes.

An Extended Home Visit Programme Within the Swedish Child Healthcare System for First-Time Parents in Scania, Sweden: A Study Protocol.

Background: The Swedish Child Healthcare (CHC) system aims to provide equal and fair health care for all children and families in Sweden. Currently in Sweden, the CHC offers every family two home visits during the child's 1st year of life. During 2019, an extended home visit programme, called Grow Safely, was started in the region of Scania for first-time parents. The aim of the extended home visit programme was to provide support for first-time parents in order to improve the overall health of the child and family and contribute to better conditions for equal health. Instead of two home visits during the 1st year, a subsample of first-time parents would receive six visits during the child's first 15 months. These six visits would be conducted by CHC nurses and social workers, midwives, and dental assistants. In the present paper, we describe a research project related to the regional extended home visit programme; the project aims to illuminate the experiences of the participants and to investigate the perceived benefits of the programme in relation to improved health, social and emotional interaction between parent and child, and attitudes toward authorities and surrounding society. Method/Analysis: In order to evaluate the introduction of the intervention, three qualitative interview studies and one quantitative study with follow-up questionnaires will be conducted. Since the research project also comprises studies focusing on the implementation and expectations of politicians, civil servants, organizational managers, and professionals working within the programme, interviews within these fields will be conducted. Discussion: Sweden has a well-established CHC programme, but improvements are always possible. Previous research has shown that home visits are an effective tool to improve both the child's physical and mental health as well as the parents' well-being. However, this kind of intervention involves a significant investment from all organizations involved in the home visits; hence, it is important that the intervention is evaluated. The research project described in the present paper intends to examine the impact of the intervention, and its findings will aid decisionmakers in determining the future of the home visit programme.

Patients' experiences of initiating unplanned haemodialysis.

BACKGROUND: Many patients with end stage kidney disease initiate dialysis in an unplanned fashion and as a result experience increased morbidity, mortality and make greater demands on health care resources. To deliver care appropriate to the needs of these patients it is imperative to gain insight into the perspective of each individual. AIM: To describe the meaning of the phenomenon "initiating haemodialysis in an unplanned fashion" experienced by the participants. DESIGN: The study used a lifeworld perspective with a descriptive phenomenological approach. PARTICIPANTS: Five patients (M 4, F 1), with experiences of the phenomenon were recruited from two dialysis units in southern Sweden. APPROACH: Individual in-depth interviews were undertaken, recorded and transcribed. The texts were analysed according to Giorgi's (2009) method. FINDINGS: The essence of the phenomenon was described as a life situation characterised by a rapid decline in health and kidney function leading to unplanned initiation of haemodialysis, which resulted in not really being able to understand what had happened. The sudden initiation of haemodialysis affected each patient in various ways and gave rise to thoughts of life's meaning. Support from others, acceptance and inner strength were helpful. Patients wished for more in-depth conversations with health care professionals. CONCLUSION: Psychological support is critical. Health care professionals need to have the time and the necessary skills in communication and empathetic listening to understand the psychological trauma each patient goes through in the unplanned setting.

Continuing education: preparing patients to choose a renal replacement therapy.

BACKGROUND: Patients with progressive chronic kidney disease face a series of treatment decisions that will impact the quality of life of themselves and their family. Renal replacement therapy option education (RRTOE), generally provided by nurses, is recommended by international guidelines OBJECTIVES: To provide nurses with advice and guidance on running RRTOE. DESIGN: A consensus conference. PARTICIPANTS: Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 European countries) from units that had extensive experience in RRTOE or were performing research in this field. APPROACH: Experts brainstormed and discussed quality standards for the education team, processes, content/topics, media/material/funding and quality measurements for RRTOE. RESULTS: Conclusions and recommendations from these discussions that are particularly pertinent to nurses are presented in this paper. CONCLUSIONS: Through careful planning and smooth interdisciplinary cooperation, it is possible to implement an education and support programme that helps patients choose a form of RRT that is most suited to their needs. This may result in benefits in quality of life and clinical outcomes. APPLICATION TO PRACTICE: There are large differences between renal units in terms of resources available and the demographics of the catchment area. Therefore, nurses should carefully consider how best to adapt the advice offered here to their own situation. Throughout this process, it is crucial to keep in mind the ultimate goal - providing patients with the knowledge and skill to make a modality choice that will enhance their quality of life to the greatest degree.

Quality standards for predialysis education: results from a consensus conference.

This position statement was compiled following an expert meeting in March 2013, Zurich, Switzerland. Attendees were invited from a spread of European renal units with established and respected renal replacement therapy option education programmes. Discussions centred around optimal ways of creating an education team, setting realistic and meaningful objectives for patient education, and assessing the quality of education delivered.

Predialysis education in practice: a questionnaire survey of centres with established programmes.

BACKGROUND: There is growing evidence that renal replacement therapy option education (RRTOE) can result in enhanced quality of life, improved clinical outcomes, and reduced health care costs. However, there is still no detailed guidance on the optimal way to run such programmes. To help address this knowledge gap, an expert meeting was held in March 2013 to formulate a position statement on optimal ways to run RRTOE. Experts were selected from units that had extensive experience in RRTOE or were performing research in this field. Before the meeting, experts completed a pilot questionnaire on RRTOE in their own units. They also prepared feedback on how to modify this questionnaire for a large-scale study. METHODS: A pilot, web-based questionnaire was used to obtain information on: the renal unit and patients, the education team, RRTOE processes and content, how quality is assessed, and funding. RESULTS: Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 EU countries) participated. Nurses were almost always responsible for organising RRTOE. Nephrologists spent 7.5% (median) of their time on RRTOE. Education for the patient and family began several months before dialysis or according to disease progression. Key topics such as the 'impact of the disease' were covered by every unit, but only a few units described all dialysis modalities. Visits to the unit were almost always arranged. Materials came in a wide variety of forms and from a wide range of sources. Group education sessions were used in 3/9 centres. Expectations on the timing of patients' decisions on modality and permanent access differed substantially between centres. Common quality assurance measures were: patient satisfaction, course attendance, updated materials. Only 1 unit had a dedicated budget. CONCLUSIONS: There were substantial variations in how RRTOE is run between the units. A modified version of this questionnaire will be used to assess RRTOE at a European level.

Patients' sense of security during palliative care-what are the influencing factors?

CONTEXT: Having a sense of security is vitally important to patients who have a limited life expectancy. OBJECTIVES: We sought to identify the factors associated with patients' sense of security during the palliative care period. METHODS: We recruited 174 adult patients (65% of those eligible) from six palliative home care units. The relationship between the patients' sense of security during palliative care and individual factors was evaluated in a stepwise procedure using the generalized linear model (ordinal multinomial distribution and logit link). RESULTS: Respondents' ratings of their sense of security ranged from 1 (never) to 6 (always), with a mean value of 4.6 (SD 1.19). Patients with lower feelings of security experienced higher stress; more worry about personal finances; lower feelings of self-efficacy; a lower sense of security with the palliative care provided (lower ratings on subscales of care interaction); mastery; prevailed own identity; higher symptom intensity (especially depression, anxiety, and lack of well-being); lower health-related quality of life; lower attachment anxiety and avoidance; less support from family, relatives, and friends; lower comfort for those closest to them; and more often had gynecological cancer. Six variables (mastery, nervousness and stress, gynecological cancer, self-efficacy, worrying about personal finances, and avoidance) were selected in building the stepwise model. CONCLUSION: These findings stress the importance of palliative care services in supporting dying patients' sense of security through symptom management with a wide scope and through supporting the patients' sense of mastery, identity, and perception of a secure care interaction and also through attention to the family members' situation.

Modification and cross-linking parameters in hyaluronic acid hydrogels--definitions and analytical methods.

Definitions and methods for the quantification of degree of modification and cross-linking in cross-linked hyaluronic acid (HA) hydrogels are outlined. A novel method is presented in which the HA hydrogel is degraded by the enzyme chondroitinase AC and the digest product analyzed by size exclusion chromatography combined with electrospray ionization mass spectrometry (SEC-ESI-MS). This method allows for the determination of effective cross-linker ratio (CrR) which together with the degree of modification (MoD), determined by, e.g. (1)H NMR spectroscopy, enables the calculation of the degree of substitution (DS) and degree of cross-linking (CrD). The method, could be applicable to the major cross-linked HA hydrogels currently on the market, and is exemplified here by application to two HA hydrogels. The definitions and methods presented are important contributions in attempts to find relationships between MoD, DS and CrD to mechanical properties as well as to biocompatibility of HA hydrogels.

Angptl4 maintains in vivo repopulation capacity of CD34+ human cord blood cells.

OBJECTIVES: Methods to expand hematopoietic stem cells (HSCs) ex vivo encompass an attractive approach that would substantially broaden the clinical applicability of HSCs derived from cord blood (CB). Recently, members of the angiopoietin-like (Angptl) family of growth factors were shown to expand both murine and human HSCs. Specifically, Angptl5 has been implicated in the expansion of human NOD/SCID-repopulating cells (SRCs) ex vivo. Here, we sought to evaluate the potential of additional Angptls to expand human SRCs from CB. Additionally, the purpose of this study was to evaluate the reproducibility of Angptl-mediated expansion of SRCs across independent experiments. METHODS: Human CD34(+) cells from CB were cultured in vitro for eleven or 8 d in the presence or absence of Angptls. The reconstitution capacity of expanded cells was subsequently measured in vivo by transplantation into NOD/SCID or NSG mice and compared with that of uncultured cells. RESULTS: We report here that Angptl4 functions to maintain SRC activity of CD34(+) CB-derived cells ex vivo as assayed in NOD/SCID and NSG mice. However, all Angptls tested, including Angptl1, Angptl4, and Angptl5, were associated with variation between experiments. CONCLUSION: Our findings indicate that Angptl4 and Angptl5 can lead to increased engraftment capacity of SRCs, but more frequently, these factors are associated with maintenance of SRC activity during ex vivo culture. Thus, Angptl-mediated expansion of SRCs ex vivo is associated with more interexperimental variation than previously thought. We conclude that Angptls would be useful in instances where there is a need to maintain HSCs ex vivo, such as during transduction for gene therapy applications.

Toxicity assessment of sequential leachates of tire powder using a battery of toxicity tests and toxicity identification evaluations.

Approximately 460,000 ton of rubber are dispersed annually along the European roads due to tire wear. Tire rubber is known to leach compounds that are toxic to aquatic organisms. However, the potential effects of tire wear material on aquatic organisms at environmental relevant concentrations, and over time have so far not been extensively studied. In this study, rubber from three different tires was abraded and the powder leached in deionised water. The rubber powder was leached six times sequentially. All leachates were tested for toxicity using standardized toxicity tests including green algae (Pseudokirchneriella subcapitata, 72h growth inhibition), crustaceans (Daphnia magna, 24 and 48h immobility and Ceriodaphnia dubia, 48h survival and 9d reproduction and survival), and zebra fish eggs (Danio rerio, 48h lethality). The reproduction of C. dubia was the most sensitive endpoint tested, with an EC50 of 0.013 g L(-1) up to the third leaching of the most toxic tire, which is similar to a predicted concentration in road runoffs. The toxicity of all tires was reduced by the sequential leachings and after the sixth leaching the EC50s were >0.1 g L(-1) for all endpoints. Toxicity identification evaluations indicated that the toxicity was caused by zinc and organic compounds.

Successful low-risk hematopoietic cell therapy in a mouse model of type 1 Gaucher disease.

Hematopoietic stem cell-based gene therapy offers the possibility of permanent correction for genetic disorders of the hematopoietic system. However, optimization of present protocols is required before gene therapy can be safely applied as general treatment of genetic diseases. In this study we have used a mouse model of type 1 Gaucher disease (GD) to demonstrate the feasibility of a low-risk conditioning regimen instead of standard radiation, which is associated with severe adverse effects. We first wanted to establish what level of engraftment and glucosylceramidase (GCase) activity is required to correct the pathology of the type 1 GD mouse. Our results demonstrate that a median wild-type (WT) cell engraftment of 7%, corresponding to GCase activity levels above 10 nmoles/hour and mg protein, was sufficient to reverse pathology in bone marrow and spleen in the GD mouse. Moreover, we applied nonmyeloablative doses of busulfan as a pretransplant conditioning regimen and show that even WT cell engraftment in the range of 1%-10% can confer a beneficial therapeutical outcome in this disease model. Taken together, our data provide encouraging evidence for the possibility of developing safe and efficient conditioning protocols for diseases that require only a low level of normal or gene-corrected cells for a permanent and beneficial therapeutic outcome.

Effects of TNT leakage from dumped ammunition on fish and invertebrates in static brackish water systems.

The objective of the present study was to study the release and effect of TNT from dumped ammunition. Cleaved artillery shells were placed in static brackish water systems for 5 months, and another 12 months with 5 cm sediment burial. The toxicity was determined in bioassays with crustaceans (Nitocra spinipes and Hyalella azteca) and/or European flounder (Platichtys flesus). The water phase was analysed for TNT using colorimetric method and GC-MS. This study showed a rapid release of TNT to acutely toxic concentrations when the cleaved ammuniton was not covered with sediment under static conditions, but that the release was effectively inhibited by sediment burial of the artillery shells. Hence, at least in a short-term perspective, acute adverse effects of sediment-buried ammunition on aquatic organisms should be greatly reduced.

Murine models of acute neuronopathic Gaucher disease.

Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder caused by mutations in the glucosidase, beta, acid (GBA) gene that encodes the lysosomal enzyme glucosylceramidase (GCase). GCase deficiency leads to characteristic visceral pathology and, in some patients, lethal neurological manifestations. Here, we report the generation of mouse models with the severe neuronopathic form of GD. To circumvent the lethal skin phenotype observed in several of the previous GCase-deficient animals, we genetically engineered a mouse model with strong reduction in GCase activity in all tissues except the skin. These mice exhibit rapid motor dysfunction associated with severe neurodegeneration and apoptotic cell death within the brain, reminiscent of neuronopathic GD. In addition, we have created a second mouse model, in which GCase deficiency is restricted to neural and glial cell progenitors and progeny. These mice develop similar pathology as the first mouse model, but with a delayed onset and slower disease progression, which indicates that GCase deficiency within microglial cells that are of hematopoietic origin is not the primary determinant of the CNS pathology. These findings also demonstrate that normal microglial cells cannot rescue this neurodegenerative disease. These mouse models have significant implications for the development of therapy for patients with neuronopathic GD.

On line UV-adsorbance measurements. Summary of the EDTNA/ERCA journal club discussion. Summer 2006.

The discussion was initiated by a paper comparing the measurement of dialysis dose (Kt/V) and solute clearance using on-line ultra-violet absorbance, blood and dialysate urea and ionic dialysance by Uhlin et al (NDT 2006). Participants from 14 countries discussed the theory behind the UV absorbance technique and the potential for its use in routine practice, the correlation between Kt/V measured using different methods, the use of ionic dialysance and the optimisation of dose monitoring. The 'take-home' messages from the discussion were that UV-absorbance could help ensure the delivery of dialysis dose as it provides real time feedback on the effect interventions such as repositioning of needles. The technology is relatively inexpensive and requires no consumables but changes in the dialysis machine settings could lead to misleading measurements if not communicated to the UV monitor. Session-to-session variation in dialysis dose can be measured using on-line clearance monitoring. If it is already on the machine and costs nothing, why not use it? Alternatively, regular access recirculation checks and a record of the total blood volume processed at each session allow problems with delivered dialysis dose to be picked up between routine blood tests.

Plant availability of nutrients recovered as solids from human urine tested in climate chamber on Triticum aestivum L.

Recovered nutrients by freezing-thawing from human urine in combination with struvite precipitation and nitrogen adsorption on zeolite and activated carbon have been tested in pot trials with wheat, Triticum aestivum L., in a climate chamber during 21 days. A simple test design using sand as substrate was chosen to give a first, general evaluation of the nutrient (P and N) availability from these sources. Dry weight, plant growth morphology, total-P and total-N were analysed. The tests show a slow-release of nutrients (P and N) from struvite and from N-adsorbents. The nitrogen in all treatments was in the deficiency range for optimum yield for wheat. Higher pH than usual for soil tests contributed to the difficulties in plant uptake, especially in the pots with only struvite (with highest MgO addition) as nutrient source.

Recovery of N and P from human urine by freezing, struvite precipitation and adsorption to zeolite and active carbon.

The majority of the nutrients in domestic waste originate from human urine. This study deals with methods for recovery of N and P from urine. Results from a freezing-thawing method (FTM) together with struvite recovery and nitrogen adsorption on zeolite and active carbon (AC) are presented. Various amounts of MgO, zeolite and AC were added to samples of 100ml urine. After 3 days the supernatants were analysed for pH, total-N, total-P and acute toxicity for Daphnia magna. One set of samples was frozen and then thawed and the supernatants collected were tested as before. The FTM method concentrated 60% of the nutrients in 40% of the initial volume and significantly improved the N reduction and D. magna survival. The P recovery was 95-100%, mainly as struvite. No significant effect of AC was found. Zeolite improved the P recovery and in some combinations of MgO also the N recovery.

TNT leakage through sediment to water and toxicity to Nitocra spinipes.

The fate and effects of 2,4,6-trinitrotoluene (TNT) at marine ammunition dumping sites are essentially unknown. The objective of this study was to examine the release from solid TNT to seawater when covered by sediment of two different types (sandy and fine-grained) and thickness (0, 1, 2, and 4 cm), under different temperatures (5, 10, and 20 degrees C), and light conditions (ambient daylight and darkness) in the laboratory. The water column was analysed for TNT and some of its common transformation products, and toxicity to the copepod Nitocra spinipes after 1, 2, 4, 8, 19, and 32 weeks. Leakage of TNT to seawater and the toxicity to N. spinipes was significantly reduced by sediment burial, especially in fine-grained sediment. Hence, this study suggests that adverse effects of TNT in dumped ammunition on aquatic organisms should be delayed/reduced at low temperature and when TNT is covered sediment, especially with fine-grained sediment.