Search

Idiopathic pulmonary fibrosis (IPF) remains a challenging disease with no drugs available to change the trajectory. It is a condition associated with excessive and highly progressive scarring of the lungs with remodelling and extracellular matrix deposition. It is a highly "destructive" disease of the lungs. The diagnosis of IPF is challenging due to continuous evolution of the disease, which also makes early interventions very difficult. The role of vascular endothelial cells has not been explored in IPF in great detail. We do not know much about their contribution to arterial or vascular remodelling, extracellular matrix changes and contribution to pulmonary hypertension and lung fibrosis in general. Endothelial to mesenchymal transition appears to be central to such changes in IPF. Similarly, for epithelial changes, the process of epithelial to mesenchymal transition seem to be the key both for airway epithelial cells and type-2 pneumocytes. We focus here on endothelial and epithelial cell changes and its contributions to IPF. In this review we revisit the pathology of IPF, mechanistic signalling pathways, clinical definition, update on diagnosis and new advances made in treatment of this disease. We discuss ongoing clinical trials with mode of action. A multidisciplinary collaborative approach is needed to understand this treacherous disease for new therapeutic targets., Competing Interests: Declaration of competing interest S.S. Sohal reports honorarium for lectures from Chiesi, travel support from Chiesi, AstraZeneca and GSK, and research grants from Boehringer Ingelheim and Lung Therapeutics, outside the submitted work; and has served on the small airway advisory board for Chiesi Australia for which an honorarium has been received., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim was to explore nurse assistants´ experiences of paying attention to and encountering patients receiving municipal health and social care, who are in grief due to the death of a loved one., Methods: A qualitative study with focus group interviews ( n  = 6) was conducted with nurse assistants (NAs) ( n  = 28) in municipal health and social care ( n  = 5) in southern Sweden. The data were analysed inductively using qualitative content analysis., Results: Three categories (1) Noticing changes in the patient , (2) Using different strategies to create a dialogue with the patient , (3) Experiencing challenges when encountering patients in grief , included eight sub-categories were identified. The result is captured in the theme of Having to be attentive to signs of grief after patients´ loss of loved ones, sensing the right time to approach and comfort, while having to cope with emotional challenges., Conclusions: The NAs encountered expressions of strong emotions from patients in grief, and even expressions of a desire to end their lives. Additionally, the NAs had to deal with their own emotions that were evoked when meeting patients in grief. These challenges indicate the need for enhanced conditions in the work culture, and improved training and supervision in health and social care.

Aim: To explore and describe older persons' unique experiences of care encounters with home care nurses in a real-life context., Background: The increasing number of older persons in society contributes to increases in age-related impairments compromising their quality of life. Future care consists of "hospitals at home" where care encounters occur in a person's private domain, partly becoming a clinical workplace. Scant research has focused on how older persons experience care encounters with home care nurses and needs to be highlighted., Design: Multiple-case study., Methods: The cases relied on replication logic and five purposive sampled older persons were interviewed. Data were analysed using qualitative content analysis and differences within and between cases were explored and findings across the cases were replicated., Findings: The cross-analysis emerged in three categories: "Nursing routine rules the care encounters", "Lack of knowledge and information" and "Dependency on support from others"., Conclusions: Our research has found that older persons face challenges while receiving home care, including limited engagement in their care and the need for enhanced support. Implementing person-centred care in homes poses ethical challenges that require careful consideration. Home care nurses should prioritise understanding each patient individually, recognising them beyond their patient role, which necessitates more thorough and time-sensitive care encounters., Reporting Method: Findings were reported using COREQ guidelines., Patient or Public Contribution: Patients were interviewed and contributed with data for this study., Implications for the Profession and Patient Care: This study emphasises the need to prioritise individualised care in home settings and listen to the voices of older individuals to enhance quality., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objective: This is a preplanned, health economic evaluation from the LIGRO trial. One hundred patients with colorectal liver metastases (CRLM) and standardized future liver remnant <30% were randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or two-staged hepatectomy (TSH)., Summary Background Data: TSH, is an established method in advanced CRLM. ALPPS has emerged providing improved resection rate and survival. The health care costs and health outcomes, combining health-related quality of life (HRQoL) and survival into quality-adjusted life years (QALYs), of ALPPS and TSH have not previously been evaluated and compared., Methods: Costs and QALYs were compared from treatment start up to 2 years. Costs are estimated from resource use, including all surgical interventions, length of stay after interventions, diagnostic procedures and chemotherapy, and applying Swedish unit costs. QALYs were estimated by combining survival and HRQoL data, the latter being assessed with EQ-5D 3L. Estimated costs and QALYs for each treatment strategy were combined into an incremental cost-effectiveness ratio (ICER). Nonparametric bootstrapping was used to assess the joint distribution of incremental costs and QALYs., Results: The mean cost difference between ALPPS and TSH was 12,662€, [95% confidence interval (CI): -10,728-36,051; P = 0.283]. Corresponding mean difference in life years and QALYs was 0.1296 (95% CI: -0.12-0.38; P = 0.314) and 0.1285 (95% CI: -0.11-0.36; P = 0.28), respectively. The ICER was 93,186 and 92,414 for QALYs and life years as outcomes, respectively., Conclusions: Based on the 2-year data, the cost-effectiveness of ALPPS is uncertain. Further research, exploring cost and health outcomes beyond 2 years is needed., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The understanding of inhaled particle respiratory tract deposition is a key link to understand the health effects of particles or the efficiency for medical drug delivery via the lung. However, there are few experimental data on particle respiratory tract deposition, and the existing data deviates considerably when comparing results for particles > 1 μm., Methods: We designed an experimental set-up to measure deposition in the respiratory tract for particles > 1 μm, more specifically 2.3 μm, with careful consideration to minimise foreseen errors. We measured the deposition in seventeen healthy adults (21-68 years). The measurements were performed at tidal breathing, during three consecutive 5-minute periods while logging breathing patterns. Pulmonary function tests were performed, including the new airspace dimension assessment (AiDA) method measuring distal lung airspace radius (r AiDA ). The lung characteristics and breathing variables were used in statistical models to investigate to what extent they can explain individual variations in measured deposited particle fraction. The measured particle deposition was compared to values predicted with whole lung models. Model calculations were made for each subject using measured variables as input (e.g., breathing pattern and functional residual capacity)., Results: The measured fractional deposition for 2.3 μm particles was 0.60 ± 0.14, which is significantly higher than predicted by any of the models tested, ranging from 0.37 ± 0.08 to 0.53 ± 0.09. The multiple-path particle dosimetry (MPPD) model most closely predicted the measured deposition when using the new PNNL lung model. The individual variability in measured particle deposition was best explained by breathing pattern and distal airspace radius (r AiDA ) at half inflation from AiDA. All models underestimated inter-subject variability even though the individual breathing pattern and functional residual capacity for each participant was used in the model., Conclusions: Whole lung models need to be tuned and improved to predict the respiratory tract particle deposition of micron-sized particles, and to capture individual variations - a variation that is known to be higher for aged and diseased lungs. Further, the results support the hypothesis that the AiDA method measures dimensions in the peripheral lung and that r AiDA , as measured by the AiDA, can be used to better understand the individual variation in the dose to healthy and diseased lungs., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Competing Interests: The author reports no conflicts of interest.

Background: Quality cancer care necessitates opportunities for patient participation, supposedly recognizing the individual's preferences and experiences for being involved in their health and healthcare issues. Previous research shows that surgical cancer patients wish to be more involved, requiring professionals to be sensitive of patients' needs., Aims: To explore preference-based patient participation in surgical cancer care., Methods: A cross-sectional study was conducted. The Patient Preferences for Patient Participation tool (4Ps) was used, which includes 12 attributes of preferences for and experiences of patient participation. Data were analyzed with descriptive and comparative statistical methods., Results: The results are based on a total of 101 questionnaires. Having reciprocal communication and being listened to by healthcare staff were commonly deemed crucial for patient participation. While 60% of the patients suggested that taking part in planning was crucial for their participation, they had experienced this only to some extent. Learning to manage symptoms and phrasing personal goals were items most often representing insufficient conditions for preference-based patient participation., Linking Evidence to Action: To support person-centered surgical care, further efforts to suffice preference-based participation are needed, including opportunities for patients to share their experiences and engage in the planning of healthcare activities., (© 2022 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.)

Background: This study compared postoperative outcomes and survival rates of patients who underwent simultaneous or staged resection for synchronous colorectal cancer liver metastases., Methods: Between 2005 and 2018, 126 patients were registered prospectively at a university hospital in Sweden, 63 patients who underwent simultaneous resection were matched against 63 patients who underwent staged resection., Results: The length of hospital stay was shorter for the simultaneous resection group, at 11 vs 16 days, p = <0.001. Fewer patients experienced recurrence in the simultaneous resection group 39 vs 50 patients, p = 0.012. There were no significant differences in disease-free survival and overall survival between the groups. Age (hazard ratio [HR] 1.72; 95% CI 1.01-2.94; p = 0.049) and Clavien-Dindo score (HR 2.22; 95% CI 1.06-4.67; p = 0.035) had impact on survival., Conclusion: Colorectal cancer with synchronous liver metastases can be resected simultaneously, and enables a shorter treatment time without jeopardizing oncological outcomes., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To evaluate the oncological outcome for patients with colorectal liver metastases (CRLM) randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH)., Background: TSH with portal vein occlusion is an established method for patients with CRLM and a low volume of the future liver remnant (FLR). ALPPS is a less established method. The oncological outcome of these methods has not been previously compared in a randomized controlled trial., Methods: One hundred patients with CRLM and standardized FLR (sFLR) <30% were included and randomized to resection by ALPPS or TSH, with the option of rescue ALPPS in the TSH group, if the criteria for volume increase was not met. The first radiological follow-up was performed approximately 4 weeks postoperatively and then after 4, 8, 12, 18, and 24 months. At all the follow-ups, the remaining/recurrent tumor was noted. After the first follow-up, chemotherapy was administered, if indicated., Results: The resection rate, according to the intention-to-treat principle, was 92% (44 patients) for patients randomized to ALPPS compared with 80% (39 patients) for patients randomized to TSH (P = 0.091), including rescue ALPPS. At the first postoperative follow-up, 37 patients randomized to ALPPS were assessed as tumor free in the liver, and also 28 patients randomized to TSH (P = 0.028). The estimated median survival for patients randomized to ALPPS was 46 months compared with 26 months for patients randomized to TSH (P = 0.028)., Conclusions: ALPPS seems to improve survival in patients with CRLM and sFLR <30% compared with TSH., Competing Interests: The authors declare no conflict of interests., (Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss and recovery. Only one randomized study is available, which showed enhanced functional recovery after LDP compared with ODP., Methods: Consecutive patients evaluated at a multidisciplinary tumour board and planned for standard distal pancreatectomy were randomized prospectively to LDP or ODP in an unblinded, parallel-group, single-centre superiority trial. The primary outcome was postoperative hospital stay., Results: Of 105 screened patients, 60 were randomized and 58 (24 women, 41 per cent) were included in the intention-to-treat analysis; there were 29 patients of mean age 68 years in the LDP group and 29 of mean age 63 years in the ODP group. The main indication was cystic pancreatic lesions, followed by neuroendocrine tumours. The median postoperative hospital stay was 5 (i.q.r. 4-5) days in the laparoscopic group versus 6 (5-7) days in the open group (P = 0·002). Functional recovery was attained after a median of 4 (i.q.r. 2-6) versus 6 (4-7) days respectively (P = 0·007), and duration of surgery was 120 min in both groups (P = 0·482). Blood loss was less with laparoscopic surgery: median 50 (i.q.r. 25-150) ml versus 100 (100-300) ml in the open group (P = 0·018). No difference was found in the complication rates (Clavien-Dindo grade III or above: 4 versus 8 patients respectively). The rate of delayed gastric emptying and clinically relevant postoperative pancreatic fistula did not differ between the groups., Conclusion: LDP is associated with shorter hospital stay than ODP, with shorter time to functional recovery and less bleeding. Registration number: ISRCTN26912858 ( www.isrctn.com)., (© 2020 The Authors. British Journal of Surgery published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Purpose: Patients' involvement in their own care is important for those with upper abdominal tumours. Care is often conducted according to standardized fast-track care programs (FTCP), and a shorter hospital stay is one of the goals. However, there is no research providing an in-depth perspective on patients' experiences of involvement in care. In this qualitative study, we explored experiences of involvement among patients who had surgery for upper abdominal tumours and were cared for according to an FTCP., Methods: Qualitative in-depth face-to-face interviews about patient involvement in care were conducted with 20 patients who had surgery for the liver, bile duct, or pancreatic cancer using an open-interview guide., Results: The most important findings are that customized information and active dialogue about care decisions stimulate patient involvement. We identified three themes from the analysed data: involvement depended on the quality of information, communication and involvement during the care period, and safety at discharge., Conclusions: Individualized care and continuous information about treatment and care goals in the FTCP during the care process create trust between patients and healthcare professionals and increase patient experiences of involvement.

Background: Earlier nonrandomized studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss, and recovery. Only one randomized study has been conducted showing reduced time to functional recovery after LDP compared with ODP., Methods: LAPOP is a prospective randomized, nonblinded, parallel-group, single-center superiority trial. Sixty patients with lesions in the pancreatic body or tail that are found by a multidisciplinary tumor board to need surgical resection will be randomized to receive LDP or ODP. The primary outcome variable is postoperative hospital stay, and secondary outcomes include functional recovery (defined as no need for intravenous medications or fluids and as the ability of an ambulatory patient to perform activities of daily life), perioperative bleeding, complications, need for pain medication, and quality of life comparison., Discussion: The LAPOP trial will test the hypothesis that LDP reduces postoperative hospital stay compared with ODP., Trial Registration: ISRCTN, 26912858 . Registered on 28 September 2015.

Background: Portal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy are lack of volume increase and tumor progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks., Methods: Patients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30% treated with PVO were prospectively included. All patients had at least one CT evaluation before radical hepatectomy., Results: Forty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT (p < 0.05). For patients reaching adequate FLR and therefore treated with radical hepatectomy, the KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume (p = 0.4). During the interval between the first and second CT, the KGR was 2.2 (± 2), respectively (± 0.1) (p = 0.017)., Discussion: The increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.

Objective: The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT)., Background: Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression., Methods: A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome-RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention., Results: Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%-100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%-72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6-26.6); P < 0.0001]. No differences in complications (Clavien-Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4-2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3-6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9-7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS., Conclusion: ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.

Difficult situations which occur intraoperatively have a direct impact on nurses working within the area. A study was undertaken focusing nurses' confrontations with difficult situations where the narrations from twelve nurses were taped. A phenomenological method was used to analyse this information and revealed how difficult intraoperative situations arise and how the nurses found different ways of handling these situations.

Most knee or hip replacement surgery is performed under regional anesthesia, when patients are awake. Previous research has primarily focused on patients' experiences during general anesthesia. The aim of this study was to uncover the meaning of being awake during regional anesthesia and surgery. Nine interviews with patients undergoing knee or hip replacement surgery comprise the data. The phenomenological analysis shows that being awake during surgery can be compared with walking a tightrope because of ambiguous feelings. Four interrelated constituents further elucidated the patients' experiences: balancing between proximity and distance in the operating theater, balancing between having control and being left out, my partly inaccessible body handled by others, and the significant role of the carer. Anesthesia providers and perioperative nurses need to understand the awake patients' intraoperative experiences to support and confirm them when they can no longer experience or have full access to their body., (Copyright © 2012 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

This article analyses problem situations in the context of anaesthesia care. It considers what it means for nurse anaesthetists to be in problematic situations in the anaesthesia care of older patients. Benner's interpretive phenomenological approach proved useful for this purpose. Paradigm cases are used to aid the analysis of individual nurses' experiences. Thirty narrated problematic anaesthesia care situations derived from seven interviews were studied. These show that experienced nurse anaesthetists perceive anaesthesia care as problematic and highly demanding when involving older patients. To be in problematic anaesthesia care situations means becoming morally distressed, which arises from the experience or from being prevented from acting according to one's legal and moral duty of care. An important issue that emerged from this study was the need for an ethical forum to discuss and articulate moral issues, so that moral stress of the kind experienced by these nurse anaesthetists can be dealt with and hopefully reduced.

Aim: The aim of the study was to use the experiences of emergency nurses to illuminate what constitutes good nursing care for patients 75 years or older transferred to emergency departments., Background: Emergency departments have a medical technical character and the number of visits there increases dramatically as people age. Older patients require increased healthcare services in terms of nursing care, interventions and hospitalizations due to an increased complexity of their problems. For these reasons it is important to study what good nursing care of the older patients consists of at an emergency department from the emergency nurses' point of view., Method: Ten emergency nurses from a university hospital emergency department in Sweden were interviewed. A thematic content analysis was performed., Results: The study showed that it was necessary to be knowledgeable, to be understanding of the older patients' situation and to take responsibility for them in order to be able to provide good nursing care. The emergency nurses shifted focus from describing the central aspect of good nursing care to describing what hinders the provision of it. Their experience was that prioritizing medical procedures, everyday tasks and routines threatens good nursing care of older patients in emergency departments. The emergency nurses held that the older patient is often sent to an emergency department where the level of care is not appropriate to their needs., Conclusions: The result can be seen as a challenge for the organization and the nurses in the future; to prioritize differently, thereby maintaining a balance between good nursing and medical/technical tasks when treating older patients., Relevance to Clinical Practice: The present day healthcare system is not organized to appropriately meet the needs of the older patients. Nurses themselves hold they can better serve the older patient. By sharing their experiences, both can be accomplished.

Background: In Sweden and internationally, little research has focused on the working situation of Enrolled Nurses and Nurses' Aides who form the majority of workers in geriatric care today. With this in mind, it is important to focus on how these occupational groups experience their working situation with older residents in municipal care., Aims and Objectives: The aim of the study was to investigate the deeper meaning of work satisfaction and work dissatisfaction at a newly opened nursing home for older residents. The study focused on the narratives supplied by the caregivers at the nursing home. The participants included: one Registered Nurse, sixteen Enrolled Nurses, and three Nurses' Aides. All were directly involved in patient care., Design: The present study is part of a larger longitudinal study within the municipal geriatric care system in Sweden, with a quasi-experimental design., Method: The interviews were analysed with a phenomenological-hermeneutic method inspired by the philosophy of Ricoeur., Result: The caregivers experiences of work satisfaction and work dissatisfaction was expressed in four themes: (i) 'Experience of betrayal' describes how the staff felt let down in several ways; (ii) 'Experience of failing others' describes how the staff felt that they did not pay enough attention to older people, in several different ways; (iii) 'Experience of insufficiency' describes how the staff encountered overwhelming demands from several directions; (iv) 'Experience of work satisfaction' describes how the staff felt that they were given support in various ways. Each theme emerged from several subthemes that originated from the caregivers' narratives., Conclusions: The study shows that the caregivers' experience of work dissatisfaction overshadows their experience of work satisfaction. It also suggests that their feelings of failing the older residents are connected to their own experiences of feeling betrayed., Relevance to Clinical Practice: The findings can be used when other nursing homes in municipal care are opened, as a means of preventing work dissatisfaction and increasing work satisfaction among future employees.

The aim of this study was to describe, through observations and interviews with patients >/=75 years old and the relatives who accompanied them to the hospital, the conditions at the emergency department (ED) and the events that took place during the waiting period. Twenty older patients were studied, together with their relatives. A modification of a comparative design, the interpretative method 'grounded theory', was utilized. Open, nonparticipant observations were carried out; from the time patients were admitted until the time they were discharged. Patients were observed through all stages, for example, in the reception area, in the examination room, and in the X-ray department. The observations were supplemented with field notes and interviews with the older patients as they left the ED. The selective coding developed into six core-variables that were the focus of the material. These were: unpleasant waiting, unnecessary waiting, lack of good routines during the waiting stage, suffering during the waiting stage, bad feelings during the waiting stage and nursing care during the waiting stage. The way, in which nursing care was carried out, which in this context is discussed in terms of praxis and poieses, appeared to be of major importance for the older peoples' experiences when visiting the ED.

Background: In a previous study, nine caregivers and two residents with dementia showing aggressive behaviour, were video recorded. Caregivers who reported problems when dealing with such behaviour and caregivers, who did not, were included in this study., Aim: The aim of the present study was to obtain insight into the reasoning of the caregivers who had reported problems when dealing with older people with dementia and aggressiveness and those who did not relative to their respective video-recorded interactions with these residents. A further aim was to gain insight by discussing their reasoning in relation to each other., Method: Stimulated recall interviews were carried out with all the caregivers who had been video taped in the previous study. The text was analysed by thematic content analysis., Findings: Two main ways of thinking and discussing the care situations emerged. The caregivers, who had reported problems in handling behavioural and psychiatric symptoms in dementia earlier, reasoned that they were more focused on their duties, this included being responsible for the resident receiving her weekly shower. For this group of caregivers, the well being of the resident was in focus, but their attention was concentrated on the resident's well being and comfort after their shower. However, these caregivers seemed therefore unwittingly to prevent a positive interaction with the resident. The other caregivers were able to reflect spontaneously and appeared to be self-critical. This caregiver group seemed to sustain a positive interaction with the resident both during and after the shower., Relevance to Clinical Practice: In this study a nurturing and supportive climate and competence seemed to be the conditions necessary to facilitate reflections and promote creativity in the caregivers such that they are able to develop possible ways of handling difficult situations like aggressiveness in residents with dementia.

Five enrolled nurses (ENs) were interviewed as part of a comprehensive investigation into the narratives of registered nurses, ENs and patients about their experiences in an acute care ward. The ward opened in 1997 and provides patient care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The ENs were interviewed concerning their experience of being in ethically difficult care situations and of acute care work. The method of phenomenological-hermeneutic interpretation inspired by the French philosopher Paul Ricoeur was used. The most prominent feature was the focus on relationships, as expressed in concern for society's and administrators' responsibility for health care and the care of older people. Other themes focus on how nurse managers respond to the ENs' work as well as their relationships with fellow ENs, in both work situations and shared social and sports activities. Their reflections seem to show an expectation of care as expressed in their lived experiences and their desire for a particular level and quality of care for their own family members. A lack of time could lead to a bad conscience over the 'little bit extra' being omitted. This lack of time could also lead to tiredness and even burnout, but the system did not allow for more time.

The aim of the study was to illuminate, from video recorded sequences, interactions between individuals with dementia and aggressive behaviour and caregivers who reported problems dealing with such behaviour and caregivers who did not. Nine caregivers and two residents participated. The video recordings were later transcribed into text and analysed by using a phenomenological hermeneutic approach, inspired by Ricoeur's philosophy. The main themes that emerged from the analysis were 'Being involved and developing a positive interaction' and 'Being confined to routines and remaining in negative interaction'. The findings indicated the interactions either to be in a positive or negative spiral. Caregivers who had reported problems dealing with behavioural and psychiatric symptoms in dementia focused on accomplishing the task, where the main focus was on 'the goal itself'. In other sequences with caregivers who had been satisfied with their capability the focus was placed on 'how' the caregivers could reach their goal. Power was central in the material, in different ways, either as a possible way to handle the situation or as a possible way of defending oneself. Parts of Kitwood's framework and Fromm's theory about power 'over' and power 'to', has been used in the comprehensive understanding. Our conclusion is that caregivers should use power 'to' when they have to help persons with dementia and aggressive behaviour, as a part of behavioural and psychiatric symptoms of dementia, for being able to give help in the best possible way. They should also act in a sensitive and reflective manner, with the individual in focus.

The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides. In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision. Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role - a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence. Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished. Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear. If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.

This qualitative study identifies and describes different ways in which newly graduated nurse anesthetists (NAs) experience and perceive nurse anesthesia. It explains different approaches to nurse anesthesia care and, thus, to clinical nursing care (in an anesthesia and surgical context), provided by new NAs. One month after graduation, all NAs who had completed an anesthesia nursing program responded to 4 open-ended questions. A phenomenographic method was used to analyze their responses. The results were divided into 3 categories, which describe nurse anesthesia from the perspectives of (1) maintaining physical well-being; (2) being protectors and advocates; and (3) ability to perform good nurse anesthesia given all the demands placed on the NAs. The results indicate that, for the new NAs, the nurse anesthesia care situation was largely influenced by context and generated feelings of inadequacy because the NAs could not provide the emotional support that they believed their patients required.

Palladium(II)-catalyzed 1,4-chloroacetoxylation of 2-aryl-1,3-cyclohexadienes 2a and 2b resulted in a highly regio- and stereoselective reaction to give cis-1-acetoxy-3-aryl-4-chloro-2-cyclohexenes 7a and 7b, respectively. The phenyl adduct 7a was subjected to the synthesis of exo- and endo-2-phenyl-7-azabicyclo[2.2.1]heptanes (exo-1a and endo-1a). Stereoselective allylic nucleophilic substitution of the chloro group in 7a by tosylamide with either retention or inversion and hydrolysis to give 9a and 14a, respectively, followed by hydrogenation, cyclization, and deprotection afforded the target molecules. Interestingly, stereoselective hydrogenation of intermediates 9a and 14a afforded the required 1,2-cis and 1,2-trans relationships, respectively, between the nitrogen and the phenyl group. In an analogous manner, 7b was transformed to exo-12b, which previously has been converted to epibatidine.