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En del av sjuksköterskans grundläggande arbete är att identifiera olika faktorer som kan påverka patienters upplevelse av smärta och smärtuttryck. För att en sjuksköterska skall kunna se en balans mellan effekt och biverkningar samt använda sig av nödvändig övervakning av smärtlindringen behövs kunskap. Föreliggande studies syfte var att belysa hur sjuksköterskor upplever sina kunskaper om och erfarenheter av intravenös smärtbehandling. I studien besvarade 35 sjuksköterskor arbetande på kirurgiska vårdavdelningar på ett sjukhus i södra Sverige, en enkät med såväl öppna som slutna frågor. De öppna frågorna analyserades med hjälp av manifest innehållsanalys. Resultatet visade att majoriteten av sjuksköterskorna upplevde att de hade tillräckliga kunskaper i att administrera intravenös smärtbehandling. Erfarenhet och utbildning var de främsta påstående sjuksköterskorna beskrev. Både som något de hade men även något som sjuksköterskorna vill ha mer av för att känna sig säkrare i sin roll som sjuksköterskor när det gällde att behandla smärta hos patienter. Även att fördjupa och få uppdaterad kunskaper om till exempel olika läkemedel var något majoriteten av sjuksköterskorna önskade. Cirka 59 procent av sjuksköterskorna administrerade mellan 1-10 procent av smärtbehandlingen som intravenös smärtbehandling. De flesta av sjuksköterskornas kunskaper grundade sig på praktisk tillämpning. / A part of the nurse’s fundamental work is to identify different factors which can affect the patient’s experience of pain and pain expression. If a nurse should be able to see a balance between the effects, the side-effects and use necessary supervision of the pain management, she needs knowledge. The aim of this study was to illuminate how nurse’s feel about their knowledge and experience of intravenous pain management. A questionnaire with both closed-ended and open-ended questions was applied as a method. The nurses were working at some of the surgery wards at a hospital in the south of Sweden. It was 35 nurses who answered the questionnaire. When analysing the open-ended questions the writers used manifest content analysis. The result showed that the majority of the nurse’s thought that they had enough knowledge to administering intravenous pain management. Having experience and education were the most common answer that the nurses gave. It was both something that they had but also something they wanted more of. Than they could be more secure in their role as nurses, when they treated patients with pain. The majority of the nurses wanted also to have a deeper and updated knowledge in different medicines. About 59 percent of the nurse’s administrates between 1-10 percent intravenous pain management. Most of the nurse’s knowledge was based on practical application.

Les terres rares (ETR) sont de plus en plus utilisées dans le développement des technologies de dernière génération. Leur usage est sans cesse croissant dans les pays industrialisés. Le Canada s’est récemment tourné vers l’exploitation du scandium (Sc). Il n’existe pourtant aucune donnée de surveillance biologique de l’exposition à ce contaminant et aucune étude toxicocinétique publiée pour ce métal à ce jour afin d’aider à interpréter les données de surveillance biologique. Dans le but d’explorer la toxicocinétique du Sc, des doses de 0,3 ou 1 mg /kg p.c. d’oxyde de scandium (Sc203) ont été administrées par voie intraveineuse (IV), dans la veine jugulaire, à des rats mâles Sprague-Dawley. La voie intraveineuse a été utilisée comme voie de référence et les rats mâles Sprague-Dawley ont été sélectionnés sur la base d’études toxicocinétiques antérieures. Des prélèvements séquentiels de sang sur 14 jours et des excrétas sur 21 jours ont été effectués, et les organes (foie, rate, reins, poumons, cerveau) ont été recueillis après le sacrifice des rats au jour 21. La spectrométrie de masse à plasma à couplage inductif (ICP-MS) a permis la quantification du Sc dans les différents organes et tissus. Les résultats obtenus montrent des différences dans la cinétique en fonction de la dose administrée. Dans le sang, les niveaux maximums ont été observés au premier temps de prélèvement, soit à 5 minutes post-exposition et représentent en moyenne (± écart-type) 1,1 ± 0,96 % de la dose administrée de 0,3 mg/kg p.c. et 0,31 ± 0,14 % de dose de 1 mg/kg p.c., suivie d’une élimination sanguine biphasique. À partir des profils temporels dans le sang, un temps de résidence moyen (MRTIV) du Sc dans l’organisme de 19,7 ± 5,9 et 43,4 ± 24,6 h a été calculé pour les doses de 0,3 et 1 mg/kg p.c. respectivement. Indépendamment de la dose, une rétention tissulaire a été observée en particulier dans le foie (8,9 ± 6,4% pour la dose faible et 4,6 ± 1,1% pour la dose élevée) et les poumons (10,6 ± 6,2% et 3,4 ± 2,3% respectivement) et l’excrétion n’était pas complète à 21 jours. Bien qu’une faible fraction de la dose ait été retrouvée dans l’urine (0,06 ± 0,02% et 0,02 ± 0,005% d’excrétion cumulative sur 21 jours respectivement pour la faible dose et la dose élevée), la voie fécale s’est avérée la principale voie l’élimination du Sc de l’organisme chez les rats, avec une excrétion cumulative sur 21 jours respective de 76,8 ± 5,6% et 23,8 ± 2,3% aux doses de 0,3 et 1 mg/kg p.c.. Ces résultats mettent en exergue l’importance du poumon et du foie comme sites de rétention majeure et questionnent sur le risque toxicologique chez les travailleurs exposés par inhalation. De plus, considérant la faible fraction excrétée dans l’urine, ils remettent en question l’usage de l’urine comme matrice fiable pour le suivi biologique de l’exposition aux ETR. / Rare earth elements (REEs) are increasingly used in the development of emerging technologies. Their use is constantly increasing in industrialized countries. Canada has recently turned to the exploitation of scandium (Sc). However, there are no biological monitoring data on exposure to this emerging contaminant and no published toxicokinetic studies for this metal to date to help interpret biological monitoring data. To investigate the toxicokinetics of Sc, doses of 0.3 or 1 mg/kg bw of scandium oxide (Sc2O3) were injected intravenously (IV), via the jugular vein, into male Sprague-Dawley rats. The IV route was used as the reference route and male Sprague-Dawley rats were selected based on previous toxicokinetic studies. Sequential 14-day blood and 21-day excreta samples were collected, and major organs (liver, spleen, kidney, lung, brain) were collected after sacrifice of the rats on day 21. Inductively coupled plasma mass spectrometry (ICP-MS) was used to analyze Sc levels. The results obtained showed differences in the kinetics of Sc at the different doses explored. In blood, the maximum levels were observed at the first sampling time, i.e. at 5 minutes post-exposure, and represented on average (± standard deviation) 1.1 ± 0.96% of the 0.3 mg/kg bw dose and 0.31 ± 0.14 % of the 1 mg/kg bw dose, followed by a biphasic blood elimination. From the blood concentration-time profiles, a mean residence time (MRTIV) of Sc in the body of 19.7 ± 5.9 and 43.4 ± 24.6 h was calculated for the 0.3 and 1 mg/kg bw doses, respectively. Regardless of dose, tissue retention was observed particularly in the liver (8.9 ± 6.4% for the low dose and 4.6 ± 1.1% for the high dose) and lungs (10.6 ± 6.2% and 3.4 ± 2.3%, respectively) and excretion was not complete by 21 days. Although a small fraction of the dose was detected in the urine (0.06 ± 0.02% and 0.02 ± 0.005 % cumulative 21-day excretion for the low and high dose, respectively), the fecal route was the main route of elimination of Sc from the body in rats with a cumulative 21-day excretion of 76.8 ± 5.6% and 23.8 ± 2.3% at the 0.3 and 1 mg/kg bw doses, respectively. These results show the importance of the lung and liver as the main retention sites and raise questions about the toxicological risk in workers exposed by inhalation. Moreover, the low fraction of Sc excreted in urine questions its use as a reliable matrix for the biological monitoring of REE exposure.

People who inject drugs, particularly opioids, are a growing population, especially in North Philadelphia. This population is at high risk for medical complications that require hospitalization. While hospitalized, this population poses unique challenges to the healthcare system, including high costs and readmission rates, as well as stress and burnout among providers and staff. These patients are at high risk of discharges against medical advice because of complicated social factors as well as inadequate recognition of pain and withdrawal. As the opioid epidemic evolves, previous strategies for managing these patients, which traditionally relied on referral to psychiatry or social work in addition to symptomatic treatment, need to be re-evaluated. Ethically, the decision-making capacity of these patients is frequently called into question, and there is a difficult-to-strike balance between respecting their autonomy and acting with beneficence to provide the best care. There are also public health concerns that come into play. Better acknowledgment of the issues that this population faces, and better management of pain and withdrawal, may improve their outcomes, as well as reduce provider stress and burnout. / Urban Bioethics

<p dir="ltr">The periparturient period involves coordinated physiological adaptations as the dairy cow transitions from a non-lactating to lactating state. The ability of dairy cattle to adapt to the onset of lactation is impacted both by physiological and nutritional factors, and a poor transition can result in reduced productivity and welfare for the animal. Additionally, disease and disorder development are heightened in the transition period, with increased risk for involuntary culling occurring in early lactation. This study aimed to evaluate if the amount of late gestational muscle reserves and prepartum supplementation of branched-chain volatile fatty acids (BCVFA) impacts health and production parameters in multiparous, periparturient dairy cattle. Forty-eight multiparous Holstein dairy cattle were assigned to either a high or low muscle group (HM or LM, respectively) based on their <i>longissimus dorsi</i><i> </i>muscle depth 42 days before expected (BEC). After assignment to group, cattle were then randomly assigned to a control (CON; 80 g/d soyhull pellets as-fed basis) or BCVFA (40 g/d isobutyrate product, 20 g/d isovalerate product, 20 g/d 2-methybutyrate product, fed as calcium salt products on an as-fed basis) treatment, which was top-dressed in the prepartum period only. After parturition, treatment was no longer provided and cattle were fed a common lactating diet. Blood samples, ultrasound images, and feed intake were collected and recorded from 42 BEC through 28 days in milk (DIM), milk yield and composition data was collected from parturition until 28 DIM.</p><p dir="ltr">HM cattle began mobilizing muscle reserves prior to parturition, while LM cattle began to accrete muscle reserves prior to parturition. This difference in prepartum muscle utilization did not impact other body measurements (i.e. body weight or body condition score) between the groups of cows but did result in increased blood glucose concentrations prepartum for HM cows compared with LM. This increase in glucose concentrations is likely due to the increased supply of gluconeogenic precursors as a result of the degradation of muscle tissue. The difference in glucose concentration was not observed postpartum, neither was there a difference in tissue mobilization between the groups postpartum. HM cattle had greater DMI both pre- and postpartum, and produced greater yields of milk, milk fat, milk protein, and milk lactose postpartum compared to the LM group. Despite the increased milk yield, there was no difference in feed efficiency between the groups, as the HM cows consumed more feed. Prepartum supplementation of BCVFA did not impact body measurement changes throughout the entire transition period, but did increase pre- and postpartum DMI, likely due to increased fiber digestibility. The BCVFA treatment increased blood glucose concentrations both pre- and postpartum and reduced milk urea nitrogen concentrations postpartum, likely due to improved nitrogen efficiency. Results show that prepartum supplementation of BCVFA has an improved ruminal carryover effect into early lactation.</p><p dir="ltr">At 14 days BEC and 7 DIM, an intravenous glucose tolerance test (IVGTT) was performed on a sub-set of cows, to evaluate if insulin response could be a mechanism impacting the efficiency and production differences observed between muscle groups and BCVFA supplementation. BCVFA supplementation increased glucose area under the curve in the prepartum period only. No other differences were observed between muscle group or treatment in either the pre- or postpartum period. Because there were no major differences between the cows in response to an IVGTT, we cannot conclude that glucose metabolism is a mechanism to explain differences in production responses observed. IVGTT cannot measure peripheral tissue insulin sensitivity, which is a limitation of this assessment, so our conclusions cannot assess if muscle reserves or BCVFA treatment impact peripheral tissue insulin sensitivity response. These results highlight that the amount of muscle plays a key role in the production responses observed in early lactation and that providing a BCVFA supplement could increase DMI during a period of negative nutrient balance and improve rumen efficiency.</p>

MCur / Department of Advanced Nursing Science / See the attached abstract below

The thesis explores chronic leg ulceration experienced by young people who inject drugs (PWID). The applied health research study, in two phases, used a sequential explanatory mixed methods design. Phase 1 involved a survey of 200 people who injected drugs to investigate the prevalence of skin problems and leg ulceration, together with the identification of risk factors for ulceration. Phase 2 involved a series of fifteen qualitative semi-structured interviews that explored the results relating to risk factors with a sample of PWID who had experienced leg ulceration, and investigated participants’ perceptions of appropriate harm reduction methods. Main findings There were three research questions in this study: 1) What is the extent of skin problems and chronic leg ulceration in young people who inject drugs? The study identified a high prevalence of leg ulceration as 15%. 60% of the sample had experienced a skin problem. Each reported skin complication is clearly defined. 2) What causes chronic leg ulceration in young people who inject drugs? Leg ulceration experienced by PWID in this study was directly linked to deep vein thrombosis (DVT), as well as injecting in the groin and the leg. DVT was strongly associated with groin and leg injecting. The acceptance amongst injectors of the groin and leg as a site of choice has occurred with a lack of awareness of the long-term consequences of damage to the limb. 3) What are appropriate harm reduction measures in young people who inject drugs? Harm reduction methods related to the development of leg ulceration have been absent across schools and drug services. Training for healthcare workers which enables them to identify risk factors should be developed, and harm reduction information related to leg ulceration should be included in drug education within schools, and instigated within drugs services. This applied health research has led to a number of practice-focused recommendations surrounding clinical care including early detection of venous insufficiency and accessible services to prevent, assess, and treat venous disease in PWID. The original contribution to knowledge is three-fold: 1. Leg ulcers have been found to be highly prevalent in young people who inject drugs. 2. Ulceration is predominantly caused by venous thrombosis due to injecting in the legs or groin. 3. Harm reduction related to the development of venous disease has lacked impact and effect.

L’optimisation hémodynamique péri-opératoire est une stratégie qui vise à maximaliser le transport artériel en oxygène et/ou le volume d’éjection systolique lors de chirurgie à risque. Ce concept a beaucoup évolué lors de ces trente dernières années, vers une approche plus simple, plus réalisable en pratique clinique et moins invasive. Les principales thérapeutiques utilisées dans les différents protocoles d’optimisation hémodynamique sont le remplissage vasculaire, l’administration d’agents inotropes et de vasopresseurs. Cependant, les conséquences physiopathologiques de l’agression chirurgicale peuvent impacter grandement les modalités d’administration et l’efficacité des thérapeutiques précitées. Dans la première étude, nous avons décrit l’impact de l’acidose respiratoire et métabolique (fréquemment rencontrées lors de chirurgie majeure et/ou de coeliochirurgie) sur l’efficacité des agents α et β-adrénergiques sur le myocarde sain de rat. Dans un deuxième travail nous avons mis en évidence que le remplissage vasculaire ne pouvait pas être guidé par des indices dynamiques de précharge dépendance lors du clampage chirurgicale de l’aorte abdominale sous-rénale, dans un modèle porcin. Enfin, dans la troisième étude, nous avons montré dans un modèle clinique, que le positionnement en décubitus ventral lors d’une chirurgie du rachis entrainait des modifications majeures des interactions cardiorespiratoires et que les indices dynamiques devaient être interprétés avec prudence pour guider le remplissage vasculaire dans ce contexte. Ces études translationnelles soulignent trois situations fréquentes impactant l’efficacité et/ou les modalités d’administration des thérapeutiques nécessaires à une optimisation hémodynamique peropératoire / The aim of perioperative haemodynamic optimization is to maximize oxygen delivery and/or stroke volume during high risk surgery. This concept has evolved during the last thirty years, to a simpler, more feasible and less invasive approach. Main treatments used in different hemodynamic optimization protocols are fluid loading, inotropes and vasopressors administration. However, pathophysiological consequences of surgical stress can greatly impact the mode of administration and the efficacy of the above therapeutics. In the first study, we described the impact of respiratory and metabolic acidosis (frequently encountered during major surgery and/or laparoscopic surgery) on the effectiveness of α and β-adrenergic agents in healthy rat myocardium. In a second work, we demonstrated that intravenous fluids cannot be guided by dynamic indices of preload dependency during surgical clamping of the infrarenal abdominal aorta in a porcine model. Finally, in the third study, we demonstrated in a clinical model, that positioning in prone position during spine surgery induced major changes in cardiorespiratory interactions and dynamic indices should be interpreted with caution to guide fluid therapy in this context. These translational studies highlight three common situations impacting the effectiveness and/or administration of therapeutic necessary for intraoperative hemodynamic optimization.

BACKGROUND: The needle exchange programme (NEP) started in Sweden in 1986 in Lund and shortly after in Malmo. The first NEP in Stockholm opened in spring 2013. The NEP is a service aimed at intravenous drug users (IDU) from 18 years old, with a goal of preventing the blood borne diseases, such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV). With the on going HIV and Hepatitis epidemics, numerous countries around the world have adopted control strategies, such as the NEP to halt the spread of HIV, HBV, and HCV. The objective of this study was to examine if the needle exchange programme has decreased the incidence of HIV, HBV, and HCV in Sweden over a six-year period.  METHODS: Data for incidence and prevalence was extracted from the yearly reports of the Stockholm’s needle exchange programme from 2013 to 2018 and the yearly reports of the public health agency in Sweden from 2013 to 2018. The data was collected for Stockholm, and compared to Västra Götaland, and the whole of Sweden. RESULTS: The incidence of HIV was zero in 2013 and 2015 in the NEP. The incidence of HBV decreased to zero in 2013 in the NEP. There is an increased incidence of HCV in the NEP. CONCLUSION: The NEP has a protective effect through its combination of needle exchange, opiate substitute therapy, counselling, and vaccinations in reducing and stabilising incidences of the infections, in some instances to zero, as well as providing surveillance and treating infections.

Introdução: A incompatibilidade de medicamento resulta de um fenômeno físico-químico causado pela combinação de dois ou mais medicamentos na mesma solução ou misturados em um mesmo recipiente. Pode ser considerado um erro de medicação pelo potencial de comprometer negativamente o tratamento. Objetivo: Estimar a incidência de incompatibilidades potenciais de medicamentos administrados por via intravenosa e fatores associados em pacientes críticos. Método: Coorte retrospectiva conduzida com pacientes internados nas Unidades de Terapia Intensiva e Semi-intensiva do Hospital Universitário da Universidade de São Paulo. A amostra foi composta por 110 indivíduos adultos hospitalizados, por pelo menos 72 horas, nessas unidades e submetidos à terapia intravenosa. A incompatibilidade potencial de medicamento foi analisada em duplas de medicamentos, utilizando-se a ferramenta Trissel´s TM 2 Compatibility IV, através da base de dados Micromedex 2.0®. A variável dependente foi a ocorrência de incompatibilidade. As variáveis independentes foram idade, sexo, procedência, tipo de internação, tempo de permanência, SAPSII, índice de Charlson, carga de trabalho de enfermagem, condição de alta, modo de infusão, número de medicamentos prescritos e de prescritores. Na análise dos dados utilizaram-se os testes qui-quadrado de Pearson, Exato de Fisher, Kruskal-Wallis, modelo de análise de variância ANOVA e regressão logística, com significância de p 0,05. Resultados: A incidência de incompatibilidade potencial de medicamentos foi de 2,7%. Foram prescritos 72 tipos diferentes de medicamentos que formaram 565 duplas, destas, 44,9%, foram compatíveis e 8,8%, incompatíveis. O aparecimento de precipitação (50,0%) foi a alteração físico-química mais identificada, após as combinações via dispositivo em Y. Na frequência de aparecimento, as duplas de medicamentos incompatíveis formadas por fenitoína (32,0%), diazepam (14,0%), midazolam (10,0%) e dobutamina (8,0%) foram as mais identificadas. Cerca de 70% dos pacientes receberam medicamentos prescritos a critério médico, principalmente durante o período noturno. Os fatores de riscos associados à incompatibilidade foram procedência (RC: 1,506; IC: 0,327 - 6,934); tempo de permanência prolongado nas unidades (RC: 1,175; IC: 1,058 - 1,306); maior número de medicamentos prescritos (RC: 1,395; IC: 1,091 -1,784) e carga elevada de trabalho de enfermagem (RC: 1,060; IC: 1,010 -1,113). Conclusão: O número de medicamentos prescritos aos pacientes críticos, em decorrência da gravidade clínica, aumenta exponencialmente a ocorrência de incompatibilidade e, os expõe a graves consequências. Embora haja outros estudos que identifiquem as incompatibilidades potenciais, observa-se, no cotidiano das unidades críticas, a repetição de rotinas que comprometem a segurança do paciente. A incompatibilidade poderá ser teoricamente diminuída, quando houver ênfase nas medidas preventivas e na contínua educação da equipe multidisciplinar. / Introduction: Drug incompatibility results from a physicochemical phenomenon caused by the combination of two or more drugs in the same solution or mixed in a single container. It can be considered a medication error due to its potential to compromise the treatment. Objective: To estimate the incidence of potential incompatibilities of drugs administered intravenously and associated factors in critically ill patients. Methods: Retrospective cohort study conducted with patients in Intensive and Semi-intensive Care Units at the University Hospital of the University of São Paulo. The sample consisted of 110 adults hospitalized for, at least 72 hours, in these units and submitted to intravenous therapy. The potential drug incompatibility was analyzed in pairs of drugs, using the TM Trissel\'s 2 Compatibility IV tool through Micromedex 2.0® database. The dependent variable was the occurrence of incompatibility. The independent variables were age, gender, origin, type of admission, length of stay, SAPSII, Charlson index, nursing workload (NAS), discharge condition, infusion mode, number of prescription drugs and prescribers. To analyze the data we used the chi-squared Pearson tests, Fisher Exact test, Kruskal-Wallis, ANOVA model and logistic regression, with significance p 0.05. Results: The incidence of potential incompatibility of drugs was 2.7%. Seventy-two 72 different types of drugs were prescribed forming 565 pairs of which 44.9% were compatible and 8.8%, incompatible. The precipitation onset (50.0%) was most identified physical-chemical change after the combinations via device Y. In frequency of appearance, the pairs of drugs formed by phenytoin (32.0%), diazepam (14.0%), midazolam (10.0%) and dobutamine (8.0%) were the most identified. About 70% of the patients received prescription drugs to medical criteria, especially during the night. Risk factors associated with the incompatibility were origin (OR: 1.506; CI: 0.327 to 6.934); prolonged length of stay in the units (OR: 1.175; CI: 1.058 to 1.306); greater number of prescribed medications (OR: 1.395; CI: 1.091 -1.784) and high nursing workload (OR: 1.060; CI: 1.010 -1.113). Conclusion: The number of prescription drugs to critically ill patients, due to the clinical severity, exponentially increases the occurrence of incompatibility and exposes them to serious consequences. Although there are other studies that identify the potential incompatibilities, we observe, in the daily life of critical units, repeating routines that compromise patient safety. Incompatibility can be theoretically reduced when there is emphasis on preventive measures and continuous education of the multidisciplinary team