Perspectives on existential loneliness. Narrations by older people in different care contexts

The aim was to explore existential loneliness in different long-term care contexts as narrated by older people. A qualitative secondary analysis was performed of 22 interviews with older people in residential care, home care, and specialized palliative care. The analysis started with naive reading of interviews from each care context. As these readings showed similarity with Eriksson's theory of the suffering human being, the three different concepts of suffering were used as an analytic grid. Our result indicates that suffering and existential loneliness are interrelated for frail older people. Some situations and circumstances that trigger existential loneliness are the same in the three care contexts while others differ. In residential and home care, unnecessary waiting, not feeling at home and not being encountered with respect and dignity can trigger existential loneliness while seeing and hearing others suffering can give rise to existential loneliness in residential care. In specialized palliative care, feelings of guilt and remorse are prominent in relation to existential loneliness. In conclusion, different healthcare contexts have various conditions for providing care that meet the existential needs of older people. Hopefully our results will be used as a basis for discussions in multi-professional teams and among managers.

Meetings are an Important Prerequisite for Flourishing Workplace Relationships

Relationships among colleagues, managers, and care recipients are mutually important, and need to be highlighted in workplace health promotion. The aim was to explore prerequisites for flourishing workplace relationships in a municipal healthcare setting for old people. As part of this process, we explored the staff’s suggestions on how work relationships could be improved. The study had a salutogenic and participatory approach, examining staff perceptions of what was required for flourishing relationships to be created, and their suggestions for the relationships to be more promotive. Four multi-stage focus groups, which met three times each, were conducted with staff (n = 26) in old age healthcare settings. A deductive analysis was performed, based on components of the flourishing concept: challenge, connectivity, autonomy, and competence. Informal and formal meetings at work were shown to build positively perceived relationships. The study describes meetings and relationships connected to the four components of flourishing. Suggestions for improving work relationships are also presented. This study contributes to workplace health promotion, and has a salutogenic and participatory focus on how to explore workplace relationships as a resource. The flourishing concept shows how workplace relationships can be explored as prerequisites for workplace health promotion.

Spouses' existential loneliness when caring for a frail partner late in life - a hermeneutical approach

Purpose: Spouses are in a vulnerable situation when caring for a frail partner late in life. Exploring their existential loneliness can be a way to understand more about their existential needs.

Method: A hermeneutic approach was used. Multistage focus group interviews were conducted with two groups consisting of five spouses, respectively, who met three times each. To work with the text, an approach was adapted where quotations are converted into poems in a linguistic manner.

Results: Existential loneliness can be understood as the following: 1) being in a transition from us to merely me, 2) being forced to make decisions and feeling excluded, 3) navigating in an unfamiliar situation and questioning oneself, and 4) longing for togetherness but lacking the energy to encounter other people. The main interpretation is that existential loneliness emerges when one is in moments of inner struggle, when one is forced to make impossible choices, when one is approaching and is in limit situations, and when one is experiencing the endless loss of the other.

Conclusion: For health care professionals to achieve a holistic picture, person-centeredness can be a way to make the spouses’ existential needs visible and to provide support based on their needs.

Assessment of Search Strategies in Literature-Review-Based Candidate Theses Within a Nursing Program

BACKGROUND

The majority of candidate theses in baccalaureate nursing programs in Sweden are written as literature studies. Being able to carry out a systematic and structured literature search is an essential part of thesis-related work.

AIM

The aim of the current study was to investigate changes in nursing students' search strategies in candidate theses.

METHODS

A retrospective, quantitative study design was obtained. Librarians (n = 2) and teachers (n = 4) randomly examined selected candidate theses (every third thesis, n = 89) from the years 2012, 2014, and 2016.

RESULTS

The result showed a significant improvement over the years (from 2012 and 2014 to 2016) regarding the use of a sufficient number of synonyms, matching search terms to the respective database, use of the Boolean operator OR, and the use of subject headings and free text searches. Use of the title/abstract search largely disappeared. There was a significant change in the types of searches being done. The searches have become more structured in later years as the use of block searches increased significantly; in other words, more systematic and relevant searches have been done in recent years.

CONCLUSION

The result of this study shows that the quality of the students' search strategies improved significantly during the studied years. It is recommended that search documents are used in both formative and summative assessments to evaluate students' search strategies. Educational development in the form of enhanced collaboration between librarians and teachers in nursing programs is recommended because it might help to develop student search strategies in literature-based candidate theses.

Challenges faced in daily life by persons with type 2 diabetes: A meta-synthesis

Objectives

To derive improved understanding of the implicit meanings of challenges in daily life from the perspective of persons with type 2 diabetes.

Methods

A meta-synthesis was conducted with an interpretive and constructivist approach. Four databases were searched for articles published between 2007 and 2011, producing 37 articles for analysis. Van Deurzen’s life world theory was applied as an analytic grid.

Results

Challenges in daily life with type 2 diabetes could be understood as living in a tension between opposing forces, implying a struggle with inevitable paradoxes: living in the present and for the future, trusting oneself while relying on others, and being normal while feeling changed and different.

Discussion

This synthesis adds knowledge to previous understanding of living with type 2 diabetes, revealing the complexity of daily life when struggling with a lifelong illness. Person-centred care could be used to understand what challenges diabetes may cause in family and working life and the ambivalent feelings the illness can lead to. Future research is needed to implement and evaluate a person-centred care in practice. Since new qualitative research is continuously added to this topic, metasyntheses should be undertaken regularly.

The context of care matters: Older people's existential loneliness from the perspective of healthcare professionals-A multiple case study

AIM

To explore existential loneliness among older people in different healthcare contexts from the perspective of healthcare professionals.

BACKGROUND

Professionals meet and care for older people in most care contexts and need to be prepared to address physical, psychological, social and existential needs. Addressing existential loneliness can be both challenging and meaningful for professionals and is often not prioritised in times of austerity.

DESIGN

A multiple case study design was used.

METHODS

Focus group interviews were conducted with healthcare professionals (n = 52) in home, residential, hospital and palliative care settings. The analysis was performed in two steps: firstly, a within-case analysis of each context was conducted, followed by a cross-case analysis.

FINDINGS

Differences and similarities were observed among the care contexts, including for the origin of existential loneliness. In home care and residential care, the focus was on life, the present and the past, compared to hospital and palliative care, in which existential loneliness mainly related to the forthcoming death. The older person's home, as the place where home care or palliative care was received, helped preserve the older person's identity. In hospital and palliative care, as in institutional care, the place offered security, while in residential care, the place could make older people feel like strangers. Creating relationships was considered an important part of the professionals' role in all four care contexts, although this had different meanings, purposes and conditions.

CONCLUSIONS

The context of care matters and influences how professionals view existential loneliness among older people and the opportunities they have to address existential loneliness.

IMPLICATIONS FOR PRACTICE

Support for professionals must be tailored to their needs, their education levels and the context of care. Professionals need training and appropriate qualifications to address existential loneliness related to existential aspects of ageing and care.

Encountering existential loneliness among older people: perspectives of health care professionals

PURPOSE

Existential loneliness is part of being human that is little understood in health care, but, to provide good care to their older patients, professionals need to be able to meet their existential concerns. The aim of this study was to explore health care professionals' experiences of their encounters with older people they perceive to experience existential loneliness.

METHOD

We conducted 11 focus groups with 61 health professionals working in home care, nursing home care, palliative care, primary care, hospital care, or pre-hospital care. Our deductive-inductive analytical approach used a theoretical framework based on the work of Emmy van Deurzen in the deductive phase and an interpretative approach in the inductive phase.

RESULTS

The results show that professionals perceived existential loneliness to appear in various forms associated with barriers in their encounters, such as the older people's bodily limitations, demands and needs perceived as insatiable, personal shield of privacy, or fear and difficulty in encountering existential issues.

CONCLUSION

Encountering existential loneliness affected the professionals and their feelings in various ways, but they generally found the experience both challenging and meaningful.

Resources for work-related well-being: A qualitative study about healthcare employees' experiences of relationships at work

AIMS AND OBJECTIVES

To explore municipal healthcare employees' experiences of relationships with care recipients and colleagues. The specific research questions were when do the relationships enhance well-being, and what prerequisites are needed for such relationships to occur?

BACKGROUND

Employees in health and social care for older people often depict their work in negative terms, and they often take a high number of sick leaves. Despite the heavy workload, other employees express well-being at work and highlight social relationships as one reason for this. However, a greater understanding of how these relationships can act as resources for workplace well-being is needed.

DESIGN

The design of the study was qualitative and exploratory.

METHODS

Qualitative interview studies were conducted with 23 healthcare employees in municipal health care. Thematic analysis was used to analyse the data.

RESULTS

Two themes were identified as resources for promoting relationships between employees and care recipients or colleagues: (a) Being personal-a close interpersonal relationship to a care recipient-and (b) Colleague belongingness-a sense of togetherness within the working group. Spending quality time together, providing long-term care and providing additional care were prerequisites for a close interpersonal relationship with care recipients. Trust, mutual responsibility and cooperation were prerequisites for a sense of togetherness within the working group.

CONCLUSIONS

The findings provide an empirical base to raise awareness of relationships with care recipients and colleagues as health aspects. Relationships among employees in health care are vital resources that must be considered to create sustainable workplaces and consequently improve the quality of care.

RELEVANCE TO CLINICAL PRACTICE

The results of this study advocate health promotion efforts based on interpersonal relationships at the workplace. Dialogues in the working groups, based on the employees' experiences of positive daily situations, may be a promoting method for the work-related well-being of the employees.

Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: A multistage focus group study

AIMS AND OBJECTIVES

To identify perceived challenges related to self-management among recently diagnosed adults and those with longer experience of type 2 diabetes as a foundation for the future development of a person-centred information and communication technology service.

BACKGROUND

Learning self-management of type 2 diabetes includes mastering the skills required to complete complex emotional and physical tasks. A service developed with the participation of stakeholders may be an alternative way to meet rising needs for self-management.

DESIGN

Qualitative descriptive design influenced by a participatory approach.

METHODS

Multistage focus group interviews among one group of recently diagnosed (≤3 years, n = 4) adults and one group with longer experience (≥5 years, n = 7) of type 2 diabetes.

RESULTS

Challenges in self-management in everyday life with type 2 diabetes were identified: understanding; developing skills and abilities; and mobilising personal strengths. Both groups described challenges in understanding the causes of fluctuating blood glucose and in developing and mobilising skills for choosing healthful food and eating regularly. The recently diagnosed group was more challenged by learning to accept the diagnosis and becoming motivated to change habits while the experienced group was mainly challenged by issues about complications and medications.

CONCLUSION

Adults with diabetes have different needs for support during different phases of the disease. From a person-centred perspective, it would be desirable to meet individual needs for self-management on peoples' own terms through a technological service that could reach and connect to a large number of people.

RELEVANCE TO CLINICAL PRACTICE

Diabetes nurses need to address the knowledge needs of patients with diabetes and support them in developing self-management skills. Consistent with person-centred care, practitioners should also encourage patients' abilities to mobilise their own personal strengths to maintain self-management.

Survey process quality: a question of healthcare manager approach

Purpose The purpose of this paper is to explore how healthcare first-line managers think about and act regarding workplace survey processes. Design/methodology/approach This interview study was performed at a hospital in south Sweden. First-line healthcare managers ( n=24) volunteered. The analysis was inspired by phenomenography, which aims to describe the ways in which different people experience a phenomenon. The phenomenon was a workplace health promotion (WHP) survey processes. Findings Four main WHP survey process approaches were identified among the managers: as a possibility, as a competition, as a work task among others and as an imposition. For each, three common subcategories emerged; how managers: stated challenges and support from hospital management; described their own work group and collaboration with other managers; and expressed themselves and their situation in their roles as first-line managers. Practical implications Insights into how hospital management can understand their first-line managers' motivation for survey processes and practical suggestions and how managers can work proactively at organizational, group and individual level are presented. Originality/value Usually these studies focus on those who should respond to a survey; not those who should run the survey process. Focusing on managers and not co-workers can lead to more committed and empowered managers and thereby success in survey processes.

Designing an ICT self-management service: suggestions from persons with type 2 diabetes

This paper reports the wishes and needs of people with type 2 diabetes (T2DM) for a future information and communication technology (ICT) self-management service to help manage their condition and their everyday life. Diabetes is a chronic disease affecting more and more people and placing increasing demands on health care. The self-management of diabetes includes instrumental and, decision-making skills and skills in managing daily activities, which may be supported by an ICT service. In this study we used a participatory design including two sessions of Future Workshop (FW) as part of a larger research project on the self-management of diabetes. Adults with type 2 diabetes participated in two FW sessions in which their expressed wishes and needs for an ICT service all fell under the broad category of Acceptance of the diagnosis, with three other suggestions; Trust in partnerships, Communication, and Individualized information. The participants' experience of the FW as a democratic process and their appreciation of mutual learning contributed to these results, which are consistent with the aims of person-centred care.

Impact of Chronic Heart Failure on Elderly Persons' Daily Life: A Validation Study

BACKGROUND

Knowledge about how elderly persons perceive the impact of chronic heart failure (CHF) on daily life is important when planning nursing care. For this purpose, disease specific instruments are needed. However, few instruments have been developed or tested specifically on elderly persons.

AIM

To validate a Swedish version of the Minnesota Living with Heart Failure Questionnaire (LHFQ) on elderly persons with CHF, and use it to describe the impact of CHF on daily life in the same population.

METHODS

The sample comprised of 357 persons, aged between 65 and 99, diagnosed with CHF. A questionnaire including background data, the LHFQ and the SF-12 was used.

RESULTS

A factor analysis resulted in four dimensions: physical, emotional, treatment and pleasure. LHFQ showed convergent validity and ability to discriminate between known groups. Cronbach's alpha for the total scale was 0.94. Impairments in the physical dimension were most common, especially fatigue (88%) and shortness of breath (87%).

CONCLUSIONS

The LHFQ showed satisfying psychometric properties in an elderly Swedish population with CHF and can, with minor alterations, be recommended for research and clinical use. The impact of chronic heart failure on daily life was mostly physical, but other impairments were also common.

Predictors for Health Related Quality of Life in Persons 65 Years or Older with Chronic Heart Failure

BACKGROUND

A main goal in nursing care of persons with chronic heart failure (HF) is to strengthen their health related quality of life (HRQoL). This presupposes knowledge about the relation between heart failure and HRQoL. Existing studies have shown incongruent results about whether HRQoL is affected differently depending on age or sex of elderly persons with chronic HF.

AIM

This study aimed to investigate if age, sex, disease severity, comorbidity and living conditions predict health related quality of life among persons 65 years or older with chronic HF.

METHODS

The study included a sample of 357 persons. HRQoL was measured by the Minnesota Living with Heart Failure Questionnaire and the Short Form-12 Health Survey Questionnaire. Multiple regression analyses were performed to analyse the relation between the predictors and HRQoL.

RESULTS

The main finding was that self-rated disease severity was strongly associated with HRQoL, but also age, sex, diabetes and respiratory diseases was associated with some of the dimensions of HRQoL.

CONCLUSIONS

Interventions aimed at delaying the progress of the disease, assist persons' to cope with the disease and maintain the domains of HRQoL that are still feasible could be important to improve HRQoL in elderly persons with chronic HF.

From a diagnostic and particular approach to a person-centred approach: a development project

AIMS AND OBJECTIVES

To investigate changes over time in an interdisciplinary group that was engaged in development work regarding pain and pain assessment.

BACKGROUND

The outcomes of nursing research do not always find their way to the daily care of patients. This is evident within, for instance, physical rehabilitation, where relieving patients' pain is a major challenge. To gain new understanding, develop and change, registered nurses have a great part in engaging their staff.

DESIGN

A qualitative study using a participatory action research approach was used, and a hermeneutic analysis was conducted.

METHODS

A group of three registered nurses, two assistant nurses and a physiotherapist took part in focus group sessions. This group was followed with seven repeated sessions during a period of five months from January 2010 until June 2010. A hermeneutic analysis was used.

RESULTS

The participants changed their attitudes towards the patient in pain, their own caring role and the team's role towards a more person-centred care.

CONCLUSIONS

Participation and reflection were key aspects as means to transfer knowledge into action and establish change. The participants came to the sessions, shared actively their experiences and expressed pride in the work they accomplished. This can be seen as an expression of a need to share and a joy to be working together in a person-oriented development area. In addition, the approach seemed to contribute to increased job satisfaction.

RELEVANCE TO CLINICAL PRACTICE

The participants expressed that their work resulted in a changed approach to pain and pain assessment in their daily practice at the ward. The participants were actively engaged in enhancing their work with pain and pain assessment in their own daily practice and in implementing research-based knowledge.

Social support and its association with health-related quality of life among older patients with chronic heart failure

BACKGROUND

Social support is generally known to influence health-related quality of life (HRQoL), but this association is not well explored among older patients with chronic heart failure.

AIMS

(1) To describe social support in older patients with chronic heart failure in relation to gender. (2) To investigate if age, gender, cohabitation, perceived financial situation, and disease severity are associated with social support. (3) To investigate if social support is associated with HRQoL after controlling for age, gender, and disease severity.

METHODS

Data were collected in a sample of 349 patients (≥ 65 years) with chronic heart failure. Patients' HRQoL was measured with the Minnesota Living with Heart Failure Questionnaire and the Short Form-12 Health Survey Questionnaire. The Interview Schedule for Social Interaction measured social support. Data were analysed with descriptive statistics, repeated-measure ANOVA, and multiple linear regression analyses with robust standard errors.

RESULTS

Social support was generally rated high, although being a man, living alone, perceiving a problematic financial situation, and high disease severity (NYHA) were associated with lower levels of social support. Age was not associated with social support. Social support was generally associated with HRQoL, in particular the emotional dimensions.

CONCLUSION

Taking social support into account when caring for older patients with heart failure can be of importance for improving or maintaining HRQoL.

How to make a workplace health promotion questionnaire process applicable, meaningful and sustainable

BACKGROUND

In workplace health promotion, a questionnaire could be of great use. Unfortunately, fatigue regarding answering questionnaires has recently become greater than before. An action research approach could be a possible way of increasing employee participation.

AIM

This study reports an attempt to explore key aspects for participation in, and commitment to, a workplace health promotion questionnaire process.

METHOD

The study was conducted at two wards in a Swedish hospital. Data was collected during an action research process. Data were analysed with regard to a framework of questions.

FINDINGS

The three key aspects for participation in, and commitment to, a workplace health promotion questionnaire process were: an applicable questionnaire, a meaningful questionnaire process and a continuous and sustainable questionnaire process. A structure is presented as practical advice to managers, describing how such a process could be established to be applicable, meaningful and sustainable.

CONCLUSION

This study has identified key aspects and prerequisites for questionnaire processes. The prerequisites - share decision-making, involve a core group and follow a structure - are discussed and proposed for managers and workgroups to consider in further workplace health promotion questionnaire processes.

IMPLICATIONS FOR NURSING MANAGEMENT

The key aspects and prerequisites presented could provide a stimulating standpoint or advice, useful for planning and accomplishing workplace questionnaire processes.

Telling stories from everyday practice, an opportunity to see a bigger picture: a participatory action research project about developing discharge planning

In spite of laws, rules and routines, findings from Swedish as well as international research show that discharge planning is not a simple matter. There is considerable knowledge about discharge planning, but the quality of the actual process in practice remains poor. With this in mind, a research and developmental health and social care network decided to use participation action research to explore the discharge planning situation in order to generate new ideas for development. This paper reports on the research process and the findings about our enhanced understanding about the discharge planning situation. Story dialogue method was used. The method is based on stories from everyday practice. The stories are used as 'triggers' to ask probing questions in a dialog and structured form. Local theory is developed to help the participants to find solutions for action in the practice. Our findings were that the discharge planning situation could be seen as a system including three interconnected areas: patient participation, practitioners' competence and organizational support. To reach good quality in discharge planning, all these three issues need to be developed, but not only as routines and forms. Rather, when developing a discharge planning situation, a system where relational aspects such as confidence and continuity are essential and thus needs to be considered. To achieve a change, the core problem needs to be clarified. When the issue is complex, the solution needs to consider the bigger picture and not just the parts. Telling stories from everyday practice, and to systematically reflect and analyse those in interprofessional groups can create opportunities for enhanced understanding, as well as be a vehicle for future change of practice.

Life satisfaction among older people (65+) with reduced self-care capacity: the relationship to social, health and financial aspects

AIMS AND OBJECTIVES

This study aimed at investigating life satisfaction and its relation to living conditions, overall health, self-care capacity, feeling lonely, physical activities and financial resources among people (65+) with reduced self-care capacity.

BACKGROUND

Knowledge about factors related to low life satisfaction among older people with reduced self-care capacity is sparse, although this is important in health care and nursing so that the care is adapted to their needs and perspective. Previous research has mainly focused on isolated aspects such as pain in relation to life satisfaction among older people in general and less among so those with reduced self-care capacity in general.

DESIGN AND METHOD

A subsample of 522 persons was selected from a randomly selected cross-sectional survey using a modified form of the Older Americans' Resources Schedule and Life Satisfaction Index Z.

RESULTS

The mean age in the total sample was 77.9; women (79.5) were significantly older than men (77.0). Low life satisfaction was found among women, as well as those living in special accommodations. Life Satisfaction Index Z was 15.3 (SD 5.6) in the total sample. Gender and living conditions did not explain life satisfaction whilst poor overall self-reported health and poor financial resources in relation to needs had the strongest explanatory value. Also of significant importance were loneliness, the degree of reduced self-care capacity and feeling worried.

CONCLUSION

Life satisfaction in older people with reduced self-care capacity is determined by several factors, with social, physical, mental and financial aspects probably interacting with each other; especially feeling lonely, degree of self-care capacity, poor overall health, feeling worried and poor financial resources in relation to needs. These factors need to be considered in the care of these people to preserve or improve their life satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Nursing interventions in terms of preventive home visits, rehabilitation, health education directed towards physical, psychological, social and economic aspects of importance may help to preserve or improve life satisfaction for those with reduced self-care capacity.

Self-reported stress reactivity and psoriasis-related stress of Nordic psoriasis sufferers

OBJECTIVES

The purpose of the study was to investigate the perceived influence of stress on psoriasis onset and disease severity in a large sample of psoriatics and to compare stress reactors and non-reactors with respect to psoriasis-related stress, disease severity, family history of psoriasis and sociodemographic factors.

PATIENTS/METHODS

A total of 5795 members of the Nordic psoriasis associations and 702 patients recruited from Nordic dermatologists or university clinics were asked whether their first outbreak of psoriasis occurred during times of worry and stress. They were also asked to rate the degree to which their psoriasis was influenced by stress and to complete the Psoriasis Life Stress Index, the Psoriasis Disability Index and a number of additional questions concerning sociodemographic factors.

RESULTS

Seventy-one per cent of the members and 66% of the patients reported that their psoriasis was exacerbated by stress, and 35% in both groups reported that the onset of their psoriasis occurred during a time of worry and stress. Stress reactors, scoring above the median on stress reactivity, reported greater disease severity, psoriasis-related stress and impairment of disease-related quality of life. They also reported more frequent use of tobacco, tranquillizers and antidepressants. More women than men were stress reactors, and stress reactors were more likely to have a family history of psoriasis.

CONCLUSION

Our findings confirm and extend the results of previous studies and indicate that a subgroup of psoriatics may be more psychologically reactive to their disease and its influence on everyday life. Whether this group is also physiologically more reactive to psychosocial stress remains to be investigated.

Older people in persistent pain: nursing and paramedical staff perceptions and pain management

BACKGROUND

Persistent pain is a common problem for older people. Knowledge about how nursing and paramedical staff perceive these people and what they do to relieve the pain seems scarce.

AIM

To explore nursing and paramedical staff perceptions of older people in persistent pain and their day-to-day management of pain.

METHODS

Interviews in Swedish with 52 nursing auxiliaries, Registered Nurses, physiotherapists and occupational therapists were collected from February to May 2000. The analysis was based on their stories (n = 150) about older people in persistent pain who received help in their own homes or in special accommodation. A typology of staff perceptions of pain in older people was developed. Activities to manage pain were examined using content analysis.

RESULTS

Respondents perceived the pain as real, exaggerated, trivial, care-related, endured, concealed, self-caused or inarticulate. Older people perceived as exaggerating the pain, those with care-related and self-caused pain evoked frustration in the staff, while those perceived as enduring their pain evoked satisfaction. Various strategies to manage pain were used: no activity, medication, mediating contacts, distracting activities, physical therapies, mobility, work in a gentle way, rest or relieving pressure on body part, and communication concerning pain. The activities differed between the types, as well as between staff with different professional backgrounds.

CONCLUSION

Care and treatment provided by staff should be based on older people's needs rather than on staff attitudes and preferences. The typology revealed that staff perceived older people in pain as a heterogeneous group and that their perceptions affected the pain-relieving activities that were offered. It seems urgent to address how to handle pain in older people who never complain and those who complain a great deal, as well as how to handle pain in people with impaired communicative ability. Reflective discussions on feelings related to different individuals are needed.

Living with persistent pain: experiences of older people receiving home care

BACKGROUND

Although the topic of pain among older people has received increasing interest, little is still known about how pain is experienced or handled by those who no longer manage independently but depend on professionals for help with daily living. Developing pain management for older people requires such knowledge.

AIM

To explore sense of self, sense of pain, daily living with pain, sense of others and ways of handling pain in older people with persistent pain.

METHODS

Interviews with 90 older people receiving home care from nursing auxiliaries in their own homes or in sheltered accommodation were collected from January to June 2000. A typology of older people in persistent pain was developed. Activities for handling pain were examined using content analysis.

FINDINGS

Respondents' experiences of themselves and their pain varied. Two groups of older people, considered as 'competent and proud' and 'confident and serene', expressed satisfaction in spite of pain, while the groups 'misunderstood and disappointed' and 'resigned and sad' expressed dissatisfaction. The most common strategies used were medication, rest, mobility, distracting activities and talking about pain. Respondents chose strategies by balancing the advantages of the activities against the disadvantages these brought for their daily living.

CONCLUSION

This study indicates that characteristics of the older people, such as their way of experiencing themselves, how pain affects their daily life and how they perceive effects and side-effects of pain management are areas that need to be identified when staff assess pain and plan pain management. Caring for older people in pain could be improved by listening to and believing their complaints, evaluating effects and side-effects from medications and nonpharmacological pain management and by emphasising the importance of common everyday activities such as mobility and distraction to relieve pain.

Managing pain in older persons who receive home-help for their daily living. Perceptions by older persons and care providers

Pain is a common problem for older persons who need professional help for their daily living. In this study 94 older persons (75+) in persistent pain were compared with 52 care providers concerning the pain management methods they had used/administered during the previous week and how helpful they perceived these methods to be. Interviews were based on 16 items from the original version of the pain management inventory (PMI). Both groups perceived prescribed medication, rest and distraction as the most frequently utilized methods. Specific methods such as transcutaneous electrical nerve stimulation (TENS) or bracing/splinting or bandaging the affected body part were seldom employed, although most users perceived these methods as helpful. Care providers perceived most methods for managing pain as more effective than older persons did. The results imply that care providers need skills in a variety of pharmacological and nonpharmacological methods to manage pain and a need to evaluate effectiveness of the methods in a systematic way.

Quality of life in 6497 Nordic patients with psoriasis

BACKGROUND

Disease-specific psoriasis-related quality of life (QOL) measures have recently been developed and used in several hospital-based investigations. However, little is known about the impact of psoriasis on QOL in people with psoriasis who are not referred by dermatologists.

OBJECTIVES

The purpose of the study was to investigate psoriasis-related QOL in a large sample of members of the psoriasis associations from the Nordic countries, and to compare the results with those from psoriasis patients recruited from Nordic dermatologists or Nordic University clinics.

PATIENTS AND METHODS

A total of 5795 association members and 702 patients rated their psoriasis severity and completed the Psoriasis Disability Index and the Psoriasis Life Stress Index.

RESULTS

Patients reported greater disease severity and greater impairment of QOL than members of associations, and Norwegian participants reported greater disease severity and greater impairment of QOL than participants from the remaining Nordic countries. Older and married participants reported less impairment of QOL than younger participants and those living alone. When controlling for the influence of these and other demographic and socio-economic factors, self-reported severity emerged as the most significant predictor of psoriasis-related QOL, explaining 32-26% of the variation in QOL scores, with the remaining factors only accounting for 4-5% of the variation. Although correlated with self-reported severity, Psoriasis Area and Severity Index scores were not a significant predictor of QOL in the patient sample.

CONCLUSIONS

Though self-reported severity may be the most important predictor, further research is needed to determine factors explaining the remaining variance in psoriasis-related QOL.

A transcriptional roadmap to wood formation

The large vascular meristem of poplar trees with its highly organized secondary xylem enables the boundaries between different developmental zones to be easily distinguished. This property of wood-forming tissues allowed us to determine a unique tissue-specific transcript profile for a well defined developmental gradient. RNA was prepared from different developmental stages of xylogenesis for DNA microarray analysis by using a hybrid aspen unigene set consisting of 2,995 expressed sequence tags. The analysis revealed that the genes encoding lignin and cellulose biosynthetic enzymes, as well as a number of transcription factors and other potential regulators of xylogenesis, are under strict developmental stage-specific transcriptional regulation.

Recognising pain in older adults living in sheltered accommodation: the views of nurses and older adults

Sixty-six randomly selected older adults and their contact nurses participated in interviews based on standardised assessments of pain and open-ended questions focusing how pain was expressed and recognised. The sample included older adults with normal as well as cognitively impaired function. Seventy-nine percent of older adults with normal cognition were often in pain. Contact nurses assessed pain in 57% of cognitively impaired older adults. The content in the statements showed that pain recognition was a communicative interactive process based on verbal and non-verbal expressions. The process comprised attempts to understand the cause and intention of the expression and to verify the presence of pain. Changes in mood, facial expressions and physiological responses were described less often by older adults than by their nurses. Contact nurses of cognitively impaired older adults judged immobility as the source of pain, that it was possible to see when the person was in pain and that pain was expressed by paralinguistic and body language more often than contact nurses of cognitively healthy older adults. Characteristics of nurses and older adults could facilitate or hinder pain recognition. The findings indicate a need for reflective discussions in the staff group focusing on how to perform systematic assessments of verbal and non-verbal expressions and of hindrances and facilitators for recognising pain in older adults.

[Functional evaluation of heart failure patients in primary care. The NYHA system is unreliable since intercurrent illness can give rise to similar symptoms]

A group of 158 patients with congestive heart failure was studied in detail concerning other types of morbidity. The purpose was to evaluate how often classification according to the NYHA system was disturbed by intercurrent disease with a similar set of symptoms. At the same time, a visual analogue scale for the evaluation of physical capacity was tested. Seventy-eight per cent of the patients had intercurrent disease putting them at risk of inadequate NYHA classification. There was no correlation between the patients' NYHA class and grade or type of echocardiographic ventricular dysfunction. However there was a correlation between NYHA class and the presence of intercurrent disease.

Treatment of psoriasis in the Nordic countries: a questionnaire survey from 5739 members of the psoriasis associations data from the Nordic Quality of Life Study

The data from a questionnaire-based study of 5,739 members of the psoriasis associations of Denmark, Finland, Iceland, Norway, Sweden and the Faeroe Islands showed that the two most commonly used active agents were topical steroids (89.7% total use and 49.4% present use) and calcipotriol (73.1% total use and 35.8% present use), with only small variations between the countries. Marked differences between the countries were, however, found within all other types of psoriasis therapy, including the so-called alternative treatments. Significant priorities varied between the different countries. The use of dithranol in Finland was almost twice the average. While 14.2% of Danish members had received grenz-rays within the last week only 0.1% of the Finns had been given the same treatment. Psoralen plus ultraviolet A (PUVA) was being used by 13.1% of the Finnish psoriatics compared with 3.8% of Danes, while PUVA was almost non-existent on the Faeroe Islands. The use of non-PUVA phototherapy was highest in Norway and Sweden. Almost 10% of the Danes were presently on methotrexate, which was used far more than etretinate/acitretin or cyclosporine. In contrast, Finnish patients more often received etretinate than other systemic agents, and in Iceland there was a higher present use of cyclosporine than of etretinate. The popularity of alternative therapies was highest in Iceland, where 26.6% had taken such medication during the last week. The results of the study suggest that different treatment patterns should be taken into consideration when discussing the prognosis of psoriasis in different countries.

Functional domains of yeast plasmid-encoded Rep proteins

Both of the Saccharomyces cerevisiae 2 microm circle-encoded Rep1 and Rep2 proteins are required for efficient distribution of the plasmid to daughter cells during cellular division. In this study two-hybrid and in vitro protein interaction assays demonstrate that the first 129 amino acids of Rep1 are sufficient for self-association and for interaction with Rep2. Deletion of the first 76 amino acids of Rep1 abolished the Rep1-Rep2 interaction but still allowed some self-association, suggesting that different but overlapping domains specify these interactions. Amino- or carboxy-terminally truncated Rep1 fusion proteins were unable to complement defective segregation of a 2 microm-based stability vector with rep1 deleted, supporting the idea of the requirement of Rep protein interaction for plasmid segregation but indicating a separate required function for the carboxy-terminal portion of Rep1. The results of in vitro baiting assays suggest that Rep2 contains two nonoverlapping domains, both of which are capable of mediating Rep2 self-association. The amino-terminal domain interacts with Rep1, while the carboxy-terminal domain was shown by Southwestern analysis to have DNA-binding activity. The overlapping Rep1 and Rep2 interaction domains in Rep1, and the ability of Rep2 to interact with Rep1, Rep2, and DNA, suggest a model in which the Rep proteins polymerize along the 2 microm circle plasmid stability locus, forming a structure that mediates plasmid segregation. In this model, competition between Rep1 and Rep2 for association with Rep1 determines the formation or disassembly of the segregation complex.

[Diagnosis and treatment of heart failure in primary health care. Low correlation between Pro-ANF and heart failure]

Three eastern Swedish primary care clinics serving a predominantly rural clientele monitored for 13 months all patients under 80 years of age with a diagnosis based on clinical signs alone of heart failure (n = 56) or suspected incipient heart failure (n = 62). Echocardiography was performed on all patients. For 64% of the former group, the putative diagnosis matched echocardiography findings. Results showed a purely diastolic disorder in one-fifth of all 118 patients, and a hemodynamically significant, hitherto unknown heart defect in about as many. Pro-ANF assays correlated poorly with manifest heart failure. Pharmacological treatments were registered, and at 6-month follow-up, 82% of patients with systolic failure were receiving ACE-inhibition.

Pain in older adults living in sheltered accommodation--agreement between assessments by older adults and staff

This study aimed to investigate the presence of pain, pain duration, localization(s), intensity, type and pharmacological treatment among older adults living in sheltered accommodation or receiving rehabilitation, as well as the agreement between pain assessments performed by staff and the older adults. Twenty-nine randomly selected older adults (65+ years) and the staff who looked after them participated in a structured interview based on standardized measures for pain assessment and physical, intellectual and communicative functions. Pain was found to be common, with a majority of participants experiencing it every day or all of the time. Nine out of 22 of the older adults in pain had no pain relief drugs at all. Agreement between assessments by the older adults and the staff was no higher than moderate and in general pain levels were underestimated. The findings indicate that older adults were at risk of undetected and untreated pain and the risk was even higher for those with speech difficulties. The provision of good nursing care for older adults in sheltered accommodation requires systematic routines for frequent pain assessments.

[Simplified ambulatory treatment of thrombosis. A daily dosage of subcutaneous low-molecular-weight heparin]

Of 162 patients aged 27-28 years, referred during a 12-month period to the Dept. of medicine, Norrköping Central Hospital, for deep vein thrombosis (DVT), 102 (63 per cent) were treated as out-patients with the low molecular weight heparin preparation, dalteparin (Fragmin), given subcutaneously at a standardised daily dosage of 200 U/kg. No serious thrombotic events were reported. The frequency of post-thrombotic symptoms at six months did not differ from that among hospitalised patients on standard heparin treatment. Thus, the proportion of DVT patients treated as in-patients was reduced by 50 per cent, despite a 33 per cent increase in the number of referrals for DVT during the period. At follow-up, almost 90 per cent of the patients expressed satisfaction with the out-patient routines.

Structural elements in yeast tRNAs required for homologous modification of guanosine-26 into dimethylguanosine-26 by the yeast Trm1 tRNA-modifying enzyme

In eukaryotic tRNAs, guanosines in position 26 (G26), located at the junction between the D-stem and the anticodon stem of tRNA, are usually modified to N2,N2-dimethylguanosine (m2(2)G). Although G26 is a prerequisite for biosynthesis of m2(2)G26, it is not self-sufficient for the formation of the dimethylated G26, since in exceptional cases eukaryotic tRNAs have an unmodified G26. In the yeast Saccharomyces cerevisiae the only tRNA species with an unmodified G26 is tRNAAsp. Using in vitro transcripts of this tRNA, as well as of yeast tRNAPhe, a tRNA containing m2(2)G26 in vivo, we have investigated the requirements on tRNA sequences and structures for the formation of m2(2)G26 by the yeast enzyme, i.e. in a homologous in vitro system. We have now demonstrated that G26 was efficiently dimethylated in vitro also after deletion of the entire anticodon stem and loop. We conclude that the elements necessary for a productive interaction between G26 in nuclear coded yeast tRNAs and the yeast G26 modifying enzyme are located within the core of the tRNA. For modification of G26 to m2(2)G26 via monomethylated G26, important primary and secondary structural elements in the tRNAs are a size of at least five nucleotides in the variable loop together with two G-C base pairs in the D-stem. This is the first case reported where the minimal requirements on nuclear coded tRNAs for a yeast modifying enzyme has been elucidated.

Characterization of the genes of the 2,3-butanediol operons from Klebsiella terrigena and Enterobacter aerogenes

The genes involved in the 2,3-butanediol pathway coding for alpha-acetolactate decarboxylase, alpha-acetolactate synthase (alpha-ALS), and acetoin (diacetyl) reductase were isolated from Klebsiella terrigena and shown to be located in one operon. This operon was also shown to exist in Enterobacter aerogenes. The budA gene, coding for alpha-acetolactate decarboxylase, gives in both organisms a protein of 259 amino acids. The amino acid similarity between these proteins is 87%. The K. terrigena genes budB and budC, coding for alpha-ALS and acetoin reductase, respectively, were sequenced. The 559-amino-acid-long alpha-ALS enzyme shows similarities to the large subunits of the Escherichia coli anabolic alpha-ALS enzymes encoded by the genes ilvB, ilvG, and ilvI. The K. terrigena alpha-ALS is also shown to complement an anabolic alpha-ALS-deficient E. coli strain for valine synthesis. The 243-amino-acid-long acetoin reductase has the consensus amino acid sequence for the insect-type alcohol dehydrogenase/ribitol dehydrogenase family and has extensive similarities with the N-terminal and internal regions of three known dehydrogenases and one oxidoreductase.

Efficacy and safety of itraconazole in the long-term treatment of onychomycosis

Sixty-one patients with a clinical diagnosis of onychomycosis in finger or toe nails were treated with itraconazole 100 mg/day or griseofulvin 500 mg/day for six to nine months. The infective causes were Trichophyton rubrum, Trichophyton mentagrophytes, or Trichophyton violaceum, and in two cases Candida albicans. A total of 27 finger and 390 toe nails were infected. Statistically significant intragroup reductions from baseline symptom severity values were seen at endpoint (month 6 or 9) for both treatment groups for all parameters: colour change, thickness, brittleness and unaffected area. No clinically or statistically significant differences between the treatment groups were seen at endpoint. However, the itraconazole group continued to improve during the follow-up, while the mean symptom severity ratings remained the same in the griseofulvin group. All itraconazole patients and 85% of griseofulvin patients were rated as cured or markedly improved at endpoint. Nineteen out of 26 evaluable itraconazole patients (73%) remained cured during the three month follow-up period, compared with 12 out of 17 griseofulvin patients (71%). The rather large number of drop-outs, especially among griseofulvin patients, makes it difficult to draw definitive conclusions of the symptom recurrence. Two itraconazole patients stopped medication due to an adverse event, compared to four patients in the griseofulvin group. The clinical laboratory data on itraconazole-treated patients did not show any statistically or clinically significant changes. In conclusion, itraconazole was at least as effective as griseofulvin in the treatment of onychomycosis. The itraconazole group continued to improve after the treatment was stopped. The results show that itraconazole 100 mg/day is safe and efficient in the long-term treatment of fungal nail infections.

Chromosomal Integration and Expression of Two Bacterial α-Acetolactate Decarboxylase Genes in Brewer's Yeast

A bacterial gene encoding α-acetolactate decarboxylase, isolated from Klebsiella terrigena or Enterobacter aerogenes , was expressed in brewer's yeast. The genes were expressed under either the yeast phosphoglycerokinase ( PGK1 ) or the alcohol dehydrogenase ( ADH1 ) promoter and were integrated by gene replacement by using cotransformation into the PGK1 or ADH1 locus, respectively, of a brewer's yeast. The expression level of the α-acetolactate decarboxylase gene of the PGK1 integrant strains was higher than that of the ADH1 integrants. Under pilot-scale brewing conditions, the α-acetolactate decarboxylase activity of the PGK1 integrant strains was sufficient to reduce the formation of diacetyl below the taste threshold value, and no lagering was needed. The brewing properties of the recombinant yeast strains were otherwise unaltered, and the quality (most importantly, the flavor) of the trial beers produced was as good as that of the control beer.

Recombinant brewer's yeast strains suitable for accelerated brewing

Four brewer's yeast strains carrying the alpha-ald gene of Klebsiella terrigena (ex. Aerobacter aerogenes) or of Enterobacter aerogenes on autonomously replicating plasmids were constructed. The alpha-ald genes were linked either to the ADC1 promoter or to the PGK1 promoter of yeast Saccharomyces cerevisiae. In pilot scale brewing (50 l) with three of these recombinant yeasts the formation of diacetyl in beer was so low during fermentation that lagering was not required. All other brewing properties of the strains were unaffected and the quality of finished beers was as good as that of finished beer prepared with the control strain. The total process time of beer production could therefore be reduced to 2 weeks, in contrast to about 5 weeks required in the conventional process.