Controlled Pulmonary Delivery of Carrier-Free Budesonide Dry Powder by Atomic Layer Deposition.

Ideal controlled pulmonary drug delivery systems provide sustained release by retarding lung clearance mechanisms and efficient lung deposition to maintain therapeutic concentrations over prolonged time. Here, we use atomic layer deposition (ALD) to simultaneously tailor the release and aerosolization properties of inhaled drug particles without the need for lactose carrier. In particular, we deposit uniform nanoscale oxide ceramic films, such as Al2O3, TiO2, and SiO2, on micronized budesonide particles, a common active pharmaceutical ingredient for the treatment of respiratory diseases. In vitro dissolution and ex vivo isolated perfused rat lung tests demonstrate dramatically slowed release with increasing nanofilm thickness, regardless of the nature of the material. Ex situ transmission electron microscopy at various stages during dissolution unravels mostly intact nanofilms, suggesting that the release mechanism mainly involves the transport of dissolution media through the ALD films. Furthermore, in vitro aerosolization testing by fast screening impactor shows a ∼2-fold increase in fine particle fraction (FPF) for each ALD-coated budesonide formulation after 10 ALD process cycles, also applying very low patient inspiratory pressures. The higher FPFs after the ALD process are attributed to the reduction in the interparticle force arising from the ceramic surfaces, as evidenced by atomic force microscopy measurements. Finally, cell viability, cytokine release, and tissue morphology analyses verify a safe and efficacious use of ALD-coated budesonide particles at the cellular level. Therefore, surface nanoengineering by ALD is highly promising in providing the next generation of inhaled formulations with tailored characteristics of drug release and lung deposition, thereby enhancing controlled pulmonary delivery opportunities.

Nanoengineering of Crystal and Amorphous Surfaces of Pharmaceutical Particles for Biomedical Applications.

The morphology, size, and surface properties of pharmaceutical particles form an essential role in the therapeutic performance of active pharmaceutical ingredients (APIs) and excipients as constituents in various drug delivery systems and clinical applications. Recent advances in methods for surface modification, however, rely heavily on liquid-phase-based modification processes and afford limited control over the thickness and conformality of the coating. Atomic layer deposition (ALD), on the other hand, enables the formation of conformal nanoscale films on complex structures with thickness control on the molecular level, while maintaining the substrate particle size and morphology. Moreover, this enables nanoengineering of surfaces of pharmaceutical particles also in the dry state. Successful nanoengineeering of crystal and amorphous surfaces of pharmaceutical particles is demonstrated in this study whereby functional properties, such as dissolution and dispersibility, were tailored for drug delivery applications. This expands on our initial work on ALD of alumina on pharmaceutical particles within the lower micro- to higher nanosize ranges to here probe both crystalline and amorphous lactose substrate surfaces (d50 = 3.5 and 21 µm). In addition, both water and ozone coreactants were evaluated, the latter having not been evaluated previously for pharmaceutical particles. The deposition process is carried out at ambient conditions in a fluidized bed reactor for a low number of cycles (i.e., from 4 to 14). Improved dissolution and extended release were achieved by the ALD nanoengineering of both crystalline and amorphous surfaces. This novel concept opens up exciting opportunities to produce more complex materials and structures using temperature- and moisture-sensitive drugs, e.g., targeting and drug delivery opportunities, as well as delivering new functionalities for novel applications in the pharmaceutical, medical, biological, and advanced materials fields. The prospects for advancing inhaled drug delivery are exemplified by the ALD surface nanoengineering concept.

Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: A simulated-use study.

The objective of this study was to evaluate task performance and handling errors with soft mist inhalers (SMIs) or pressurized metered-dose inhalers (pMDIs) among patients with chronic obstructive pulmonary disease (COPD) experienced with, but not recently trained in, using these devices. This exploratory, noninterventional, simulated-use study (D5970R00004) assessed handling/usability of SMIs and pMDIs in inhaler-experienced patients with COPD (40-78 years; diagnosis ≥6 months). Patients received a device and instruction-for-use leaflet but no training and were recorded while performing tasks required for checking the device, priming, and dosing. Errors that could substantially affect the lung-delivered dose were considered critical. Sixteen of 61 patients (52% male) had used SMIs and 55 had used pMDIs. Thirty-one patients received an SMI and 30 a pMDI. Overall, 79% made ≥5 performance errors (SMI 94%; pMDI 63%) and 49% made ≥5 critical errors (SMI 68%; pMDI 30%). All patients made ≥1 error; three (all pMDI) made no critical errors. Regardless of the device used and previous inhaler experience, patient-centered training, education, and continuous retraining on correct inhaler use should be key aspects of routine patient care in COPD.

Differences in clinical reasoning among nurses working in highly specialised paediatric care.

AIMS AND OBJECTIVES: The aim of the study was to examine differences in clinical reasoning among novice, experienced and specialist paediatric nurses. BACKGROUND: Highly specialised paediatric care requires specific knowledge and ongoing skill performance of the nurses employed. There is a lack of research in how paediatric nurses manage the daily care problems they encounter and how they acquire the skills required to give patients the best possible care. More knowledge is needed about how paediatric nurses with different experience and education reason and communicate about paediatric patient situations. DESIGN: The study was based on six recorded group discussions of a fictitious, but realistic paediatric case. Three categories of nurses: novices (n = 7), experienced (n = 7) and specialists (n = 7) from a paediatric hospital participated. A qualitative content analysis approach was chosen to examine differences in clinical reasoning. RESULTS: Several themes were uncovered: child's social situation, child abuse and the child's illness, qualitative differences emerged in how the nurses discussed the case. Three approaches were identified: a task-oriented approach (novices and experienced), an action-oriented approach (novices and experienced) and hypothesis-oriented approach (specialists) while discussing the case. CONCLUSION: When comparing nurses in three competence groups, it was established that the groups with extensive experience and specialist education reasoned differently than the other groups. Between the novice and experienced groups, no obvious differences were found. Thus, the importance of experience alone for the development of competence is still an open question. Experience combined with further education appears important for developing professional competence in paediatric care. RELEVANCE TO CLINICAL PRACTICE: Nurses' reasoning in clinical paediatric care is related to experience and training.

Swedish rehabilitation professionals' perspectives on work ability assessments in a changing sickness insurance system.

PURPOSE: Changes in the Swedish sickness insurance system shifts focus from return-to-work to labour market reintegration. This article analyses Swedish rehabilitation professionals' perspectives on how the changed regulations affect practice, with a special focus on work ability assessments. METHODS: Two groups of representatives (n = 15) from organizations involved in rehabilitation and return-to-work met at seven occations. The groups worked with a tutor with a problem-based approach to discuss how their practice is influenced by the changed regulations. The material was analysed inductively using qualitative content analysis. RESULTS: The new regulations require developed cooperation among insurance, health care, employers and occupational health care; however, these demands are not met in practice. In work ability assessments, several flaws regarding competence and cooperation are identified. An increasing number of people previously assessed as work disabled are required to participate in labour market reintegration, which puts demands on professionals to engage in motivational activities, although this is perceived as hopeless due to the group's lack of employability. CONCLUSIONS: The possibility for employers to sidestep their responsibility has increased with changed regulations. The overall lack of cooperation between relevant actors and the lack of relevant competence undermine the ambitions of activation and reintegration in the reform.

A matter of trust? A study of coordination of Swedish stakeholders in return-to-work.

INTRODUCTION: Stakeholder cooperation in return-to-work has been increasingly emphasized over the last years. However, there is a lack of empirical studies on the subject. This study explores different public stakeholders' experiences of participating in Coordination Associations (CAs), a Swedish form of structured cooperation in return-to-work. The aim of the study is to determine the impact of stakeholder interests on the prerequisites for cooperation. METHODS: Thirty-five representatives from two CAs in eastern Sweden were interviewed regarding the aim, structure and strategies for their common work. RESULTS: Stakeholders' actions are to a high degree determined by their institutional preferences and self-interest. In the CAs, the motives for cooperation differ, and although these differences supposedly could be overcome, they are in fact not. One of the stakeholders, the Public Employment Service, limit its interest to coordinating resources, while the other three wishes to engage in elaborated cooperative work forms, implying the crossing of organizational borders. This discrepancy can largely be attributed to the difficulties for representatives from state authorities in changing their priorities in order to make cooperation work. CONCLUSIONS: Stakeholders' interests have a high impact on the prerequisites for cooperation in return-to-work. By referring to organizational goals, stakeholders engage in non-cooperative behaviour, which threatens to spoil cooperative initiatives and to develop distrust in cooperative work forms. The results of this study expose the complexity of and threats to cooperation, and its conclusions may be used by return-to-work stakeholders in different jurisdictions to improve the possibilities for the development of cooperative structures.

The work ability divide: holistic and reductionistic approaches in Swedish interdisciplinary rehabilitation teams.

INTRODUCTION: Stakeholder cooperation in return to work has been increasingly emphasised in research, while studies on how such cooperation works in practise are scarce. This article investigates the relationship between professionals in Swedish interdisciplinary rehabilitation teams, and the aim of the article is to determine the participants' definitions and uses of the concept of work ability. METHODS: The methods chosen were individual interviews with primary health care centre managers and focus groups with twelve interdisciplinary teams including social insurance officers, physicians, physiotherapists, occupational therapists, medical social workers and coordinators. RESULTS: The results show that the teams have had problems with reaching a common understanding of their task, due to an inherent tension between the stakeholders. This tension is primarily a result of two factors: divergent perspectives on work ability between the health professionals and the Social Insurance Agency, and different approaches to cooperative work among physicians. Health professionals share a holistic view on work ability, relating it to a variety of factors. Social insurance officers, on the other hand, represent a reductionistic stance, where work ability is reduced to medical status. Assessments of work ability therefore tend to become a negotiation between insurance officers and physicians. CONCLUSIONS: A suggestion from the study is that the teams, with proper education, could be used as an arena for planning and coordinating return-to-work, which would strengthen their potential in managing the prevention of work disability.

Health care students' differing conceptions of expertise: a challenge for inter-professional care.

The aim of the study was to examine do health care students, who study at different programs, value similar expert qualities. To investigate this issue, a questionnaire was administered among health care students in a Finnish polytechnic (two cohorts, total n = 466), consisting of a scale for rating the importance of different expert qualities. The questionnaire resulted in the following dimensions of the conceptions of expertise: (1) social skills, (2) scientific skills, (3) innovativeness, (4) continuing self-development, and (5) problem-solving skills. Also the Inventory of General Study Orientations (IGSO) was applied to analyse possible motivational explanations for different conceptions of expertise. In addition to the scales, an open-ended writing task was used to explore in depth students' conceptions of expertise. It appeared that study orientations were a minor factor in the study, while study environment (study programs) clearly differentiated students' conceptions of expertise. Thus, the study argues that health care students' conceptions of expertise are constituted mainly on domain-specific bases and that students who graduate from different programs may possess very diverse ideas about their profession. Consequently, different conceptions captured during the education form a major challenge for inter-professional care later in work-life. This phenomenon should be taken into account when organising health care education.