Handovers in primary healthcare in Norway: A qualitative study of general practitioners’ collaborative experiences

Worldwide demographic development increases the pressure on healthcare services. In Norway, municipal acute wards (MAWs) have been established as a 24‐hr acute healthcare service as a primary healthcare alternative to hospitalisation. General practitioners (GPs) are key holders of referrals to different healthcare service levels, yet studies of GPs’ experiences with these wards are sparse. Suboptimal handovers could lead to hospital readmissions, avoidable morbidity and even mortality. The aim of this study was to explore GPs’ experiences with patient handovers to MAWs as well as to hospitals. A qualitative study including semi‐structured interviews with 23 GPs in a county in south‐eastern Norway was conducted. Data were analysed using thematic analysis. The results show that GPs preferred to collaborate with others in their own profession for patient handovers. The GPs had positive collaborative experiences with MAW doctors, while collaboration with doctors in hospitals was viewed more negatively, particularly as GPs had the impression that hospital doctors felt they had superior medical competence. After patient transfer, GPs felt uncertainty related to their own responsibilities for the patient. This study contributes new knowledge about GPs’ experiences with collaboration and distribution of responsibility between primary and tertiary healthcare services. This information is essential when developing acceptable alternatives to general hospitals.     

Muscular strength after total hip arthroplasty: A prospective comparison of 3 surgical approaches

ResultsDifferences in maximal strength change were greatest after 2 and 8 days. The posterior and anterior approaches produced less decrease in muscular strength than the direct lateral approach. 6 weeks postoperatively, the posterior approach produced greater increase in muscular strength than the direct lateral approach, and resulted in a greater increase in abduction strength than the anterior approach. At 3-month follow-up, no statistically significant differences between the groups were found. The operated legs were 18% weaker in leg press and 15% weaker in abduction than the unoperated legs, and the results were similar between groups.InterpretationThe posterior and anterior approaches appeared to have the least negative effect on abduction and leg press muscular strength in the first postoperative week; the posterior approach had the least negative effect, even up to 6 weeks postoperatively. THA patients have reduced muscle strength in the operated leg (compared to the unoperated leg) 3 months after surgery.Regaining muscular strength is important for postoperative function after hip arthroplasty. Inactivity reduces muscular strength and physical function (McGuire et al. 2001, Suesada et al. 2007, Kortebein et al. 2008), and muscular strength decreases substantially in the first week after total hip arthroplasty (THA) (Holm et al. 2013). Early recovery and rehabilitation of the weakened musculature is therefore of importance (Sicard-Rosenbaum et al. 2002). The type of surgical approach used has a major impact on THA stability and muscle function (Masonis and Bourne 2002).The direct lateral approach (DLA) is associated with a low dislocation risk (Witzleb et al. 2009), but of concern is that it traumatizes the abductor muscles, which can lead to permanent postoperative limp and weakness (Edmunds and Boscainos 2011). The posterior approach (PA) has been associated with postoperative dislocations (Edmunds and Boscainos 2011, Brooks 2013), mainly owing to the small femoral heads used to prevent wear (Bystrom et al. 2003). However, the introduction of highly cross-linked polyethylene into the articulation has reduced wear independently of head diameter (Bragdon et al. 2007), leading to increased use of larger head diameters (Lombardi et al. 2011). It has also been shown that a posterior soft-tissue repair following PA reduces the dislocation rate (van Stralen et al. 2003, Suh et al. 2004). The anterior approach (AA), first described by Robert Judet in 1947 as a modified Smith-Petersen approach, follows the principles of minimally invasive surgery. This approach provides intermuscular and internervous exposure to the hip (Wojciechowski et al. 2007), leading to reduced soft-tissue dissection and trauma (Bergin et al. 2011). Concerns have been related to higher complication rates owing to wound complications, intraoperative fracture, and compromised fixation after minimally invasive surgery, with increased risks of early revision surgery (Graw et al. 2010).There is no consensus on the relative functional advantages of different surgical approaches (Gulati et al. 2008, Edmunds and Boscainos 2011), and differences in maximal strength have not been examined. To our knowledge, there have been no studies comparing the DLA, the PA, and the AA in terms of early maximal muscular strength. We compared these 3 surgical approaches with regard to regaining of maximal muscular strength by 3 months postoperatively in patients undergoing THA.     

European genome-wide association study identifies SLC14A1 as a new urinary bladder cancer susceptibility gene

Three genome-wide association studies in Europe and the USA have reported eight urinary bladder cancer (UBC) susceptibility loci. Using extended case and control series and 1000 Genomes imputations of 5 340 737 single-nucleotide polymorphisms (SNPs), we searched for additional loci in the European GWAS. The discovery sample set consisted of 1631 cases and 3822 controls from the Netherlands and 603 cases and 37 781 controls from Iceland. For follow-up, we used 3790 cases and 7507 controls from 13 sample sets of European and Iranian ancestry. Based on the discovery analysis, we followed up signals in the urea transporter (UT) gene SLC14A. The strongest signal at this locus was represented by a SNP in intron 3, rs17674580, that reached genome-wide significance in the overall analysis of the discovery and follow-up groups: odds ratio = 1.17, P = 7.6 × 10(-11). SLC14A1 codes for UTs that define the Kidd blood group and are crucial for the maintenance of a constant urea concentration gradient in the renal medulla and, through this, the kidney's ability to concentrate urine. It is speculated that rs17674580, or other sequence variants in LD with it, indirectly modifies UBC risk by affecting urine production. If confirmed, this would support the 'urogenous contact hypothesis' that urine production and voiding frequency modify the risk of UBC.     

Nurses' patient-education work: conditional factors - an integrative review

friberg f., bergh a.-l. & granum v. (2012) Journal of Nursing Management 20, 170–186
Nurses’ patient-education work: conditional factors – an integrative review Aim The aim of this review was to identify conditional factors for nurses’ patient-education work and to identify foundational aspects of significance when designing studies on this patient-education work. Background A few reviews of nurses patient education work exist, published up to 30 years ago, spawning interest in performing a review of more recent studies. Evaluation A search of CINAHL, MEDLINE and ERIC was made for articles dating from 1998 to 2011. Thirty-two articles were selected and an integrative review was performed. Key issues Conditional factors were identified and beliefs and knowledge, environment, organization, interdisciplinary cooperation, collegial teamwork and patient education activities. A model was developed to describe foundational aspects of significance when designing studies. Conclusions The conditional factors are to be seen as either enabling or hindering the accomplishment of evidence-based patient education and the level of person centredness, patient safe care and ethics – something that has to be considered when designing studies. Implications for nursing management More detailed studies are required to clarify the nature of patient education work and to create realistic conditions that enable the role to be fulfilled in everyday work. Such knowledge is of significance for nursing management in developing supportive activities for nurses.     

Warfarin-associated bleeding events and concomitant use of potentially interacting medicines reported to the Norwegian spontaneous reporting system

AIMS

To study warfarin associated bleeding events reported to the Norwegian spontaneous reporting system and evaluate the differences in assessment of potentially interacting medicines between reporters and evaluators.

METHODS

Data on bleeding events on warfarin were retrieved from the Norwegian spontaneous reporting system database. Key measurements were time to bleeding, use of concomitant medications and the evaluation done by reporters.

RESULTS

In 289 case reports a total of 1261 medicines (median 4.0 per patient, range 1–17) was used. The evaluators (authors of this article) identified 546 medicines including warfarin (median 2.0 per patient, range 1–7) that could possibly cause bleeding alone or in combination. Reporters assessed 349 medicines (median 1.0 per patient, range 1–4) as suspect. Evaluators identified 156 pharmacokinetic and 101 pharmacodynamic interactions, compared with 19 pharmacokinetic and 56 pharmacodynamic interactions reported as suspected by the reporters. Time to bleeding was stated in 224 reports. Among the early bleeding events, the reports on warfarin without interacting medicines showed the highest INR (international normalized ratio). Heparin was used in 17/21 reported bleeding events during the first week on warfarin. Among the late bleeding events, reports with pharmacokinetic interacting medicines had the highest INR.

CONCLUSIONS

Concomitant use of potentially interacting medicines was involved in the majority of the warfarin-associated bleeding events reported to the Norwegian spontaneous reporting system. Reporters assessed mostly warfarin as the only contributor to bleeding. In particular, pharmacokinetically interacting medicines were not suspected as contributing to bleeding.     

Standardization, innovation and deployment of electronic referral software in Norway

The introduction of electronic referrals in Norway started in 1996, when the first standard for an electronic referral was developed. Subsequent implementations of electronic health record (EHR) systems have been tested by a national testing and approval service. Almost all the Norwegian EHR systems comply with the recommended standards, but the volume of electronic referrals remains low: only 8200 referrals were sent electronically in September 2007. In comparison, 125,000 electronic discharge summaries were sent during the same month. There are four elements that need to be in place before smooth communication can occur between the EHRs of the hospitals and the general practitioners. First, the regional health authorities must have a strategy for electronic cooperation. Second, various technical problems must be solved. Third, certain organizational problems must be addressed. Finally, electronic referrals should be used to support enhanced work processes and joint reception for referrals should be considered at larger hospitals.     

Renal oncocytoma: a clinicopathological analysis of 45 consecutive cases

OBJECTIVE: To evaluate the clinical behaviour and pathology of renal oncocytoma in a well-defined population over a 30-year period. PATIENTS AND METHODS: In a retrospective population-based study we assessed relevant clinical and pathological factors in 45 patients (31 men and 14 women) diagnosed with renal oncocytoma in Iceland between 1971 and 2000. Clinical presentation, pathology, survival and causes of death were evaluated. RESULTS: The age-standardized incidence was 0.3 per 100,000 per year for both men and women, the incidence of oncocytomas being 5.5% of renal cell carcinomas (RCCs) diagnosed during the same period in Iceland. Fourteen patients were diagnosed at autopsy for an unrelated disease. Of 31 living patients (mean age 70.5 years), seven were diagnosed incidentally (23%), and the others had presented with haematuria (32%), abdominal pain (29%), and weight loss (10%). All the patients had a radical nephrectomy, except for one with bilateral oncocytoma who had a partial nephrectomy. The mean (range) tumour size was 5.7 (0.9-12) cm. Eighteen patients (58%) were diagnosed at Tumour-Node-Metastasis stage I, 10 at stage II (32%) and three at stage III (10%), all of those at stage III having renal capsular penetration or tumour invasion into perirenal fat tissue (T3aN0M0). No patients were diagnosed with lymph node or distant metastasis. Two cases of coexisting RCC were detected. After a median follow-up of 8.3 years there were no recurrences or deaths from oncocytoma (100% disease-specific survival). The overall 5-year survival was 63%, with most patients dying from cardiovascular diseases or nonrenal cancers. CONCLUSIONS: In most cases renal oncocytoma behaves like a benign tumour; the long-term prognosis is excellent. Thus, in the present patients, radical nephrectomy could be regarded as an over-treatment and nephron-sparing surgery as more appropriate, especially in patients with small tumours. However, both coexisting RCC and perirenal fat invasion, a hallmark of malignant behaviour, might indicate that more radical surgery is warranted in some of these patients.     

Skeletal muscle lipid accumulation in type 2 diabetes may involve the liver X receptor pathway

Liver X receptors (LXRs) are important regulators of cholesterol and lipid metabolism and are also involved in glucose metabolism. However, the functional role of LXRs in human skeletal muscle is at present unknown. This study demonstrates that chronic ligand activation of LXRs by a synthetic LXR agonist increases the uptake, distribution into complex cellular lipids, and oxidation of palmitate as well as the uptake and oxidation of glucose in cultured human skeletal muscle cells. Furthermore, the effect of the LXR agonist was additive to acute effects of insulin on palmitate uptake and metabolism. Consistently, activation of LXRs induced the expression of relevant genes: fatty acid translocase (CD36/FAT), glucose transporters (GLUT1 and -4), sterol regulatory element-binding protein-1c, peroxisome proliferator-activated receptor-gamma, carnitine palmitoyltransferase-1, and uncoupling protein 2 and 3. Interestingly, in response to activation of LXRs, myotubes from patients with type 2 diabetes showed an elevated uptake and incorporation of palmitate into complex lipids but an absence of palmitate oxidation to CO(2). These results provide evidence for a functional role of LXRs in both lipid and glucose metabolism and energy uncoupling in human myotubes. Furthermore, these data suggest that increased intramyocellular lipid content in type 2 diabetic patients may involve an altered response to activation of components in the LXR pathway.