Reasoning about reasoning - using recall to unveil clinical reasoning in stroke rehabilitation teams.

PURPOSE: The study objective was to investigate how health care providers in stroke teams reason about their clinical reasoning process in collaboration with the patient and next of kin. MATERIALS AND METHODS: An explorative qualitative design using stimulated recall was employed. Audio-recordings from three rehabilitation dialogs were used as prompts in interviews with the involved staff about their clinical reasoning. A thematic analysis approach was employed. RESULTS: A main finding was the apparent friction between profession-centered and person-centered clinical reasoning, which was salient in the data. Five themes were identified: the importance of different perspectives for a rich picture and well-informed decisions; shared understanding in analysis and decision-making - good intentions but difficult to achieve; the health care providers' expertise directs the dialog; the context's impact on the rehabilitation dialog; and insights about missed opportunities to grasp the patient perspective and arrive at decisions. CONCLUSIONS: Interprofessional stroke teams consider clinical reasoning as a process valuing patient and next of kin perspectives; however, their professional expertise risks preventing individual needs from surfacing. There is a discrepancy between professionals' intentions for person-centeredness and how clinical reasoning plays out. Stimulated recall can unveil person-centered practice and enhance professionals' awareness of their clinical reasoning.

The findings provide insights into the clinical reasoning process of interprofessional stroke teams, which can increase awareness and support the development of competencies among health care providers.To increase patient participation in the clinical reasoning process, stroke teams are recommended to clarify the function of goals and the decision-making process in management.Stimulated recall is recommended as a reflective activity in the work of stroke teams to develop awareness and skills in clinical reasoning performed in collaboration between health care providers and patients.

Mussel Adhesive Protein as a Promising Alternative to Fibrin for Scaffold Fixation during Cartilage Repair Surgery.

OBJECTIVE: Fibrin has been used as a standard material for scaffold fixation during cartilage repair surgery. Most of the commercially available fibrin preparations need an additional method for scaffold fixation, most often with sutures, thus damaging the surrounding healthy cartilage. There is therefore a need to find alternatives to this method. In our study, we have investigated the potential possibility to use mussel adhesive protein as such an alternative. METHODS: In this study, hydrophobic plastic was coated with the mussel adhesive protein Mefp-1 as well as with other cell adhesives (poly-lysine, fibronectin, and collagen). Human keratinocytes and chondrocytes were seeded on these substrates at 37°C in culture medium, followed by analysis of attachment and proliferation by crystal violet staining and metabolic labelling. Performance of Mefp-1 and fibrin as tissue glues were estimated by tensional force resistance measurement of moist porcine dermis (as a correlate to scaffold) glued to dermis, cartilage, or bone at 37°C. RESULTS: Mefp-1 supported maximal cell attachment at a coating density of approximately 1 µg/cm2. This was at least as good as the other adhesives tested. In addition, it supported cell proliferation at least as good as regular tissue culture plastic over a 7-day period. Measurement of tensional force resistance showed that Mefp-1 performed equally well as fibrin when porcine dermis was glued to cartilage and bone at the same concentration. Separation of the moist tissues after 15-minute incubation required a force of approximately 1 N/cm2 for both compounds. CONCLUSIONS: Mefp-1 show properties that qualify it as a compound that potentially could replace fibrin as a tissue glue for scaffold fixation. Given the possibilities to modify this protein by bioengineering, it is likely that the properties can be further improved.

Healthcare-professional patients' conceptions of being ill and hospitalised - a phenomenographic study.

AIMS AND OBJECTIVES: To describe the variation of conceptions of being ill and hospitalised, from the perspective of healthcare-professional patients. BACKGROUND: Previous literature focuses on either physicians' or nurses' experiences of being a patient, without aiming at determining a variation of ways of understanding that phenomena. Nor have we been able to identify any study reporting other healthcare professionals' experiences. DESIGN: This study has an inductive descriptive design. METHODS: Qualitative interviews with healthcare professionals (n = 16), who had been hospitalised for at least two days. Phenomenographic data analysis was conducted. RESULTS: The feelings of security were based on knowledge, insight and trust, and acceptance of the healthcare system. Being exposed and totally dependent due to illness provoked feelings of vulnerability and insecurity. The patients used their knowledge to achieve participation in the care. The more severe they perceived their illness to be, the less they wanted to participate and the more they expressed a need for being allowed to surrender control. The patients' ideal picture of care was sometimes disrupted, and based on their experience, they criticised care and made suggestions that could contribute to general care improvements. CONCLUSIONS: Healthcare-professional patients have various conceptions of being ill and hospitalised. Based on the general nature of the many needs expressed, we believe that the insights provided in this study can be transferred so as to also be valid for lay patients. Possibly, an overhaul of routines for discharge planning and follow-up, and adopting a person-centred approach to care, can resolve some of the identified shortcomings. RELEVANCE TO CLINICAL PRACTICE: The results can be used for the purpose of developing knowledge for healthcare professions and for educational purposes.

Growth data of underprivileged children living in rural areas of Chin State, Burma/Myanmar, compared to the WHO reference growth standards: an observational study.

OBJECTIVES: To explore growth data (height-for-age, weight-for-age and BMI-for-age) of children living in poor socioeconomic conditions in rural areas of Chin State, Burma/Myanmar; and to compare these data with the growth and development z-score (GDZ) values for school-aged children and adolescents, provided by the WHO. SETTING: A support and educational programme, run by the Swedish association Chin Development and Research Society (CDRS), was carried out among underprivileged school-aged children, unable to attend school without economic and practical support, living in villages and remote areas in Chin State. PARTICIPANTS: Community leaders who were well familiar with the citizens in the community identified children in need of this support. Other community members could also suggest or apply for this. The sample includes all participating children in the CDRS programme at the time of the data collection in six townships. The children were placed in host families, close to a suitable school. Two samples with a total of 639 children from 144 villages and remote areas were obtained:1. Children in the CDRS Chin Programme (CCP) (2007-2010) comprised 558 children: 50% girls and boys.2. Children in the Chin Society (CCS) (2010) comprised 81 children: 44% girls and 56% boys. PRIMARY OUTCOME MEASURES: Growth data. RESULTS: All growth data from both groups deviated significantly from the WHO standard references (p ≤ 0.001). The prevalence of stunting (height-for-age ≤-2SD) was 52% among girls and 68% among boys. High levels of wasting (weight-for-age ≤-2SD) were found among girls 29% and boys 36% aged 5-10 years. In addition, severe thinness (BMI-for-age ≤-2SD) was found among girls 31% and boys 44%, all results to be compared to the expected 2.27%. CONCLUSIONS: Many more than expected-according to the WHO reference values-in CCP and CCS suffered from stunting, wasting and thinness.

Ways of understanding being a healthcare professional in the role of family member of a patient admitted to hospital. A phenomenographic study.

UNLABELLED: Healthcare professionals' experience of being family member of a patient can contribute to knowledge development and organizational learning in further ways than the experiences of general family members. However, there is little research on healthcare professionals' experience being on 'the other side of the bed'. OBJECTIVE: To describe how healthcare professionals understand the role of being a healthcare professional and a family member of a patient admitted to hospital. DESIGN: Qualitative with a phenomenographic approach. SETTING: Three Swedish hospitals. PARTICIPANTS: All healthcare professionals in three hospitals were invited. Twenty-one volunteered for the study and 18 met the inclusion criteria; to have one year of professional experience and to have visited the family member in hospital daily during hospitalization. Family members in maternity or psychiatric care were excluded. METHODS: Semi-structured interviews were used for data collection. Transcripts were analyzed with a phenomenographic method to describe variation and commonality in the ways of understanding the phenomenon under study. RESULTS: Four dominant ways of understanding the phenomenon were identified; the informed bystander, the supervisor, the advocate and the carer. The four ways of understanding were hierarchically related with "The informed bystander" being least involved in the care of the family member and "The carer" more or less taking over the patient's care because of inappropriate, unsafe or omitted care. Common for all ways of understanding the phenomenon, except "The informed bystander", was the difficult balance between their loyalty toward the family member and their colleagues among the staff. "The informed bystander" and "The supervisor" are ways of understanding the phenomenon under study that, to our knowledge, has not been described before. CONCLUSIONS: This study describes how being a family member of a patient can be understood in four different ways when the family member is a healthcare professional. The findings show similarities to previous studies on general family members as well as nurse-family members of patients in critical care. The need for professional communication, support and coordination will be substantially different if the family member understands his/her role as an informed bystander compared to if they perceive themselves as a carer. The role conflict and ambivalence toward building relationships described are aspects that need further exploration, as does the experience of being forced to care for a family member. Our findings contribute with new knowledge developing patient- and family-centered care.

CRIM1 is expressed at higher levels in drug-resistant than in drug-sensitive myeloid leukemia HL60 cells.

AIM: The aim of this study was to explore possible differences in the mRNA expression levels of CRIM1, SMAD5, BMP4 and BMP7 in sensitive (S) and multidrug-resistant (R0.5) myeloid leukemia HL60 cells. MATERIALS AND METHODS: HL60S and HL60R0.5 cells were exposed to daunorubicin (DNR) or cytarabine (Ara-C). RESULTS: Baseline levels of CRIM1 were found to be 15-fold higher in HL60R0.5 than in HL60S. Sixteen hours of exposure to DNR resulted in a 5.6-fold increase in CRIM1 levels in HL60S. Exposure to either DNR or Ara-C resulted in modest increases in CRIM1 levels in HL60R0.5. Similarly, baseline levels of SMAD5 and BMP4 were higher in HL60R0.5 than in HL60S cells. Analysis of the drug SMAD5-resistance marker permeability-glycoprotein (Pgp) revealed that CRIM1 and Pgp exhibit a covariance pattern of expression. CONCLUSION: This study demonstrated that CRIM1 is expressed at high levels in resistant leukemia cells, indicating that CRIM1 may play a role in drug-resistance.

Topoisomerase IIalpha expression in acute myeloid leukaemia cells that survive after exposure to daunorubicin or ara-C.

Patients diagnosed with acute myeloid leukaemia are often treated with a combination of daunorubicin and 1-beta-D-arabinofuranosylcytosine (ara-C). Both daunorubicin and ara-C exert their effects in the cell nucleus but by different mechanisms, i.e. daunorubicin causes double stranded DNA breaks by inhibition of the nuclear enzyme, topoisomerase (topo) IIalpha, whereas ara-C is an anti-metabolite that integrates with DNA during DNA synthesis and causes cell cycle arrest. Despite the initial efficacy of these drugs, resistance often develops in the clinical setting. The mechanisms underlying clinical resistance to these drugs are poorly understood, but may be associated with an increase in the proportion of topo IIalpha negative cells. Therefore, the aim of this study was to determine whether daunorubicin treatment results in increased numbers of topo IIalpha negative subpopulations in vitro. Acute myeloid leukaemia cells isolated from 12 consenting patients were treated for 24 h with increasing concentrations of daunorubicin or ara-C and the proportion of topo IIalpha-negative cells in surviving cell populations determined by flow cytometry. Treatment with daunorubicin, but not ara-C, resulted in a significant increase in the proportion of topo IIalpha negative cells (p=0.0023). These results suggest that daunorubicin may act by cell cycle arrest and/or by selection of pre-existing topo IIalpha negative subpopulations. Both of these mechanisms can theoretically contribute to a reduced efficacy of a second dose of daunorubicin. The clinical relevance of these interactions should be further elucidated in experimental and clinical studies.

Rapid induction of P-glycoprotein mRNA and protein expression by cytarabine in HL-60 cells.

BACKGROUND: Overexpression of P-glycoprotein (P-gp), breast cancer resistance protein (BCRP) and glutathione-S-transferase pi (GSTpi) is associated with drug resistance in acute myeloid leukemia (AML). The short-term effects of drug exposure on their expression levels were investigated. MATERIALS AND METHODS: HL-60 cells and drug-resistant sublines were cultured with or without daunorubicin (DNR) and cytarabine (Ara-C). At several time-points the expression levels of P-gp, BCRP and GSTpi were determined. RESULTS: After exposure to Ara-C, P-gp mRNA rapidly increased in all the cell lines. P-gp protein was detected in the sensitive cells after 8 h exposure to Ara-C. GSTpi mRNA increased in the resistant cells, but no change in BCRP mRNA was observed. Exposure to DNR revealed rapidly increased P-gp and GSTpi mRNA in the resistant cells. CONCLUSION: Ara-C rapidly increases P-gp mRNA and protein expression in sensitive and resistant cells, and GSTpi mRNA in resistant cells, in vitro. This may be of clinical importance during AML induction chemotherapy.

Translating the International Classification for Nursing Practice (ICNP)--an experience from two countries.

The International Classification for Nursing Practice (ICNP) has been published in the alpha, beta 1, and beta 2 versions that, together with forthcoming versions, are going to be translated into many languages. It is important that the translation process facilitates a valid and reliable translation. Experiences from two countries are given as well as recommendations for future work. There is a need for an ongoing development of the ICNP, including feedback from numerous countries to ICN.

In vitro chemosensitivity testing of selected myeloid cells in acute myeloid leukemia.

In several studies different chemosensitivity assays have been examined in acute myeloid leukemia (AML). Some have shown that in vitro chemosensitivity testing is an independent prognostic factor but so far no one has been able to show that the use of these methods can improve treatment outcome. In an attempt to improve in vitro chemosensitivity testing in AML we wanted to establish and evaluate a new flow cytometry chemosensitivity assay. After 4 days of incubation viable mononuclear myeloid cells were identified by the exclusion of propidium iodide in CD13 or CD33 positive cells. Sixty-eight samples from 64 AML patients were included. In this study, we showed that the flow cytometry method is feasible in AML and we also found some correlations to clinical data. The secondary AML at diagnosis showed an in vitro resistance to etoposide and amsacrine that was significantly higher compared to de novo AML at diagnosis (p = 0.04 and p = 0.02). When AML patients at diagnosis were compared to resistant disease/relapse patients there was a significantly higher effect of ara-C in the diagnosis group (p = 0.03). Responders and non-responders were compared in vitro but we found no significant differences. In vitro mitoxantrone was more effective in multidrug resistance (MDR) negative cells compared to MDR positive cells (p < 0.01). This new method is feasible and makes it possible to selectively evaluate the effect of cytotoxic drugs in myeloid cells. Further studies with a larger group of patients are needed to evaluate the predictive value of the assay.