Factors influencing non-conveyance care encounters in the ambulance service, registered nurses experiences - a qualitative study

BACKGROUND

There is a notable variation in the percentage of non-conveyed patients within the ambulance service. Discharging patients at the scene includes a risk of adverse events, and both patients and ambulance clinicians experience the complexity of non-conveyance. Therefore, this study aimed to describe factors influencing the care encounter when care in the ambulance service concludes with non-conveyance.

METHOD

A qualitative study design employing the critical incident technique for data collection through individual interviews, and a qualitative analysis based on Fridlund et al. descriptions was utilized. The study conforms to the COREQ checklist for reporting qualitative research.

RESULTS

Fourteen Registered Nurses (RN) described 30 incidents and various factors were identified as influencing the care encounter. The factors included communication, sharing information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and an overall understanding of the patient's entire situation. These factors were integrated into the RNs' decision-making process for non-conveyance.

CONCLUSION

The decision-making process for non-conveyance by RNs is a multifaceted approach that incorporates several factors. Communication, sharing of information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and a comprehensive understanding of the patient's entire situation. These findings have the potential to contribute to the development of guidelines supporting the RNs working in the ambulance service in their decisions regarding non-conveyance. Further research is needed on the patient's and relatives' perspective on non-conveyance otherwise, patient participation and partnership in person-centered care are not possible to achieve.

First-in-Human Study of the Reversible BTK Inhibitor Nemtabrutinib in Patients with Relapsed/Refractory Chronic Lymphocytic Leukemia and B-Cell Non-Hodgkin Lymphoma

Nemtabrutinib is an orally bioavailable, reversible inhibitor of Bruton tyrosine kinase (BTK) and C481S mutant BTK. We evaluated the safety, pharmacology, and antitumor activity of nemtabrutinib in relapsed/refractory hematologic malignancies. Forty-eight patients with chronic lymphocytic leukemia (CLL), B-cell non-Hodgkin lymphoma (NHL), or Waldenström macroglobulinemia (WM), relapsed/refractory after ≥2 prior therapies were enrolled in the open-label, single-arm, phase I MK-1026-001 study (NCT03162536) to receive nemtabrutinib 5 to 75 mg once daily in 28-day cycles. Dose finding progressed using a 3 + 3 dose escalation design. Primary endpoints were safety and the recommended phase II dose (RP2D). Among 47 treated patients, 29 had CLL, 17 had NHL, and 1 had WM. Grade ≥3 treatment-emergent adverse events occurred in 37 (89%), most commonly neutropenia (11; 23.4%), febrile neutropenia (7; 14.9%), and pneumonia (7; 14.9%). The RP2D was 65 mg daily. An overall response rate of 75% was observed in patients with CLL at 65 mg daily.

SIGNIFICANCE

This first-in-human phase I study demonstrates the safety and preliminary efficacy of nemtabrutinib in patients with relapsed/refractory B-cell malignancies. These data support further exploration of nemtabrutinib in larger clinical studies. This article is featured in Selected Articles from This Issue, p. 5.

Two Novel Microsporidia in Skeletal Muscle of Pike-Perch Sander lucioperca and Burbot Lota lota in Finland

Two new species of Microsporidia were recognized in skeletal muscle of freshwater fishes from Finland. Myosporidium spraguei n. sp. from pike-perch Sander lucioperca occurred as mature spores within sporophorous vesicles (SPVs) within a xenoma. The ovoid spores were 3.8 μm long and 2.4 μm wide, based on transmission electron micrographs (TEM). The exospore and endospore were equally thick, the nucleus was monokaryotic and the polar filament was isofilar with 12 coils in a single rank, entirely adjacent to the prominent posterior vacuole. Small subunit (SSU) rDNA sequence confirmed the presence of M. spraguei n. sp. in burbot Lota lota . The second species, Microsporidium luciopercae n. sp., also from pike-perch, occurred within SPVs that occupied only a fraction of the volume of the otherwise intact myocyte; no xenoma was produced. Myocyte degeneration and necrosis occurred as mature spores dispersed into direct contact with the sarcoplasm. The ovoid spores were 4.6 μm long and 2.8 μm wide (based on TEM); they were monokaryotic and the polar filament was isofilar with 25 coils in a single rank in the posterior of the spore. The exospore was relatively thin with an irregular profile. Neither infection elicited an inflammatory response, although degenerate spores were observed within host cells, suggesting phagocytosis. Phylogenetic analysis of SSU sequences placed both organisms on distinct clades within the Marinosporidia.

Algorithm for systematic peak extraction from atomic pair distribution functions

The study presents an algorithm, ParSCAPE, for model-independent extraction of peak positions and intensities from atomic pair distribution functions (PDFs). It provides a statistically motivated method for determining parsimony of extracted peak models using the information-theoretic Akaike information criterion (AIC) applied to plausible models generated within an iterative framework of clustering and chi-square fitting. All parameters the algorithm uses are in principle known or estimable from experiment, though careful judgment must be applied when estimating the PDF baseline of nanostructured materials. ParSCAPE has been implemented in the Python program SrMise. Algorithm performance is examined on synchrotron X-ray PDFs of 16 bulk crystals and two nanoparticles using AIC-based multimodeling techniques, and particularly the impact of experimental uncertainties on extracted models. It is quite resistant to misidentification of spurious peaks coming from noise and termination effects, even in the absence of a constraining structural model. Structure solution from automatically extracted peaks using the Liga algorithm is demonstrated for 14 crystals and for C60. Special attention is given to the information content of the PDF, theory and practice of the AIC, as well as the algorithm's limitations.

Ab-initio reconstruction of complex Euclidean networks in two dimensions

Reconstruction of complex structures is an inverse problem arising in virtually all areas of science and technology, from protein structure determination to bulk heterostructure solar cells and the structure of nanoparticles. We cast this problem as a complex network problem where the edges in a network have weights equal to the Euclidean distance between their endpoints. We present a method for reconstruction of the locations of the nodes of the network given only the edge weights of the Euclidean network. The theoretical foundations of the method are based on rigidity theory, which enables derivation of a polynomial bound on its efficiency. An efficient implementation of the method is discussed and timing results indicate that the run time of the algorithm is polynomial in the number of nodes in the network. We have reconstructed Euclidean networks of about 1000 nodes in approximately 24 h on a desktop computer using this implementation. We also reconstruct Euclidean networks corresponding to polymer chains in two dimensions and planar graphene nanoparticles. We have also modified our base algorithm so that it can successfully solve random point sets when the input data are less precise.

Altered expression of genes involved in lipid metabolism in obese subjects with unfavourable phenotype

Obesity (BMI ≥30 kg/m(2)) increases the risk of developing lifestyle-related diseases. A subgroup of obese individuals has been described as "metabolically healthy, but obese" (MHO). In contrast to at-risk obese (ARO), the MHO phenotype is defined by a favourable lipid profile and a normal or only slightly affected insulin sensitivity, despite the same amount of body fat. The objective was to characterize the metabolic phenotype of MHO subjects. We screened a variety of genes involved in lipid metabolism and inflammation in peripheral blood mononuclear cells (PBMC). Obese subjects (men and women; 18-70 years) with BMI ≥30 kg/m(2) were characterized as MHO (n = 9) or as ARO (n = 10). In addition, eleven healthy, normal weight subjects characterized as healthy by the same criteria as described for the MHO subjects were included. We found that with similar weight, total fat mass and fat mass distribution, the ARO subjects have increased plasma levels of gamma-glutamyl transpeptidase and free fatty acids. This group also has altered expression levels of a number of genes linked to lipid metabolism in PBMC with reduced gene expression levels of uncoupling protein 2, hormone-sensitive lipase and peroxisome proliferator-activated receptor δ compared with MHO subjects. The present metabolic differences between subgroups of obese subjects may contribute to explain some of the underlying mechanisms causing the increased risk of disease among ARO subjects compared with MHO subjects.

Plant sterols from rapeseed and tall oils: effects on lipids, fat-soluble vitamins and plant sterol concentrations

BACKGROUND AND AIMS

Data comparing the impact of different sources of plant sterols on CVD risk factors and antioxidant levels is scarce. We evaluated the effects of plant sterols from rapeseed and tall oils on serum lipids, lipoproteins, fat-soluble vitamins and plant sterol concentrations.

METHODS AND RESULTS

This was a double-blinded, randomized, crossover trial in which 59 hypercholesterolemic subjects consumed 25 g/day of margarine for 4 weeks separated by 1 week washout periods. The two experimental margarines provided 2g/day of plant sterols from rapeseed or tall oil. The control margarine had no added plant sterols. The control margarine reduced LDL cholesterol by 4.5% (95% CI 1.4, 7.6%). The tall and rapeseed sterol margarines additionally reduced LDL cholesterol by 9.0% (95% CI 5.5, 12.4%) and 8.2% (95% CI 5.2, 11.4%) and apolipoprotein B by 5.3% (95% CI 1.0, 9.6%) and 6.9% (95% CI 3.6, 10.2%), respectively. Lipid-adjusted beta-carotene concentrations were reduced by both sterol margarines (P<0.017). alpha-Tocopherol concentrations were reduced by the tall sterol compared to the rapeseed sterol margarine (P=0.001). Campesterol concentrations increased more markedly with the rapeseed sterol versus tall sterol margarine (P<0.001). The rapeseed sterol margarine increased while the tall sterol margarine decreased brassicasterol concentrations (P<0.001).

CONCLUSIONS

Plant sterols from tall and rapeseed oils reduce atherogenic lipids and lipoproteins similarly. The rapeseed sterol margarine may have more favorable effects on serum alpha-tocopherol concentrations.

Crystal structure solution from experimentally determined atomic pair distribution functions

An extension of the Liga algorithm for structure solution from atomic pair distribution functions (PDFs), to handle periodic crystal structures with multiple elements in the unit cell, is described. The procedure is performed in three separate steps. First, pair distances are extracted from the experimental PDF. In the second step the Liga algorithm is used to find unit-cell sites consistent with these pair distances. Finally, the atom species are assigned over the cell sites by minimizing the overlap of their empirical atomic radii. The procedure has been demonstrated on synchrotron X-ray PDF data from 16 test samples. The structure solution was successful for 14 samples, including cases with enlarged supercells. The algorithm success rate and the reasons for the failed cases are discussed, together with enhancements that should improve its convergence and usability.

Absorption of very-long-chain saturated fatty acids in totally hydrogenated fish oil

Partially hydrogenated fish oil (PHFO) contains a high amount of trans fatty acids (TFA). Total hydrogenation results in a minimal amount of TFA, but a high content of very-long-chain saturated fatty acids (VLCSFA). Absorption and metabolism of VLCSFA from totally hydrogenated fish oil (THFO) were studied in rats. Groups of eight rats were fed one of four diets containing 40 g soyabean oil (SBO)/kg (low-fat diet), 150 g SBO/kg (SBO diet), 40 g PHFO/kg (PHFO diet) or 40 g THFO/kg (THFO diet) for 4 weeks. A lower absorption coefficient of the fat content was found in the THFO group (61 %) compared with the other groups (PHFO 95 %, SBO 99 %, low fat 98 %; which was mainly due to reduced absorption of VLCSFA. A reduced weight gain was found for the THFO group compared with the other groups, but this was only significant when compared with the SBO group Faecal fat excretion (dry weight) was markedly increased in the THFO group (47 %), which was 2.4, 4.8 and 8.3 times higher compared with the groups fed PHFO, SBO and low-fat diets respectively. Serum total cholesterol was reduced for the PHFO and THFO groups whereas serum triacylglycerol was increased for the PHFO group compared with the other groups Animals fed THFO diet had an increased content of 20:0 and 22:0 in the serum triacylglycerol fraction whereas only 20:0 was increased in the serum phospholipid fraction The low absorption coefficient of THFO must be considered if this fat is to be used for consumption by animals or man.