Mechanical ventilation and weaning: Roles and competencies of intensive care nurses and patients' experiences of breathing.

The papers III and IV of this thesis are not available in Munin. Paper III: Haugdahl, H. S., Storli, S. L., Meland, B., Dybwik, K., Romild, U., Klepstad, P.: “Underestimation of Patient Breathlessness by Nurses and Physicians During a Spontaneous Breathing Trial”. Available in American Journal of Respiratory and Critical Care Medicine 2015, 192(12):1440-1448. Paper IV: Haugdahl, H. S., Dahlberg, H., Klepstad, P., Storli, S. L.: “The Breath of Life. Patients’Experiences of Breathing During and After Mechanical Ventilation”. (Manuscript).Breathlessness is an under-recognized problem in intensive care. The overall aims of this study were to explore the roles and competencies of nurses in mechanical ventilation (MV) and weaning, and to explore patients’ experiences of breathing during and after mechanical ventilation. A multimethod design included: survey data from leaders in Norwegian ICUs, interviews and field observations of intensive care nurses in concrete weaning situations, a prospective observational study of 100 mechanically ventilated patients’ self report of breathlessness and, a qualitatively driven sequential mixed method design combining prospective observational breathlessness data during MV and data from follow-up interviews. We found that breathlessness was prevalent among mechanically ventilated patients (62%), and underestimated by nurses and physicians, regardless of expertise or experiences. MV patients’ experiences of breathing were not necessarily a separate experience, but intertwined with the whole illness experience and existential dimensions of life. The nurses’ roles in MV and weaning are their continuous presence and vigilance detection of early changes in the patients’ condition. To acknowledge the presence and impact of breathlessness seems important. Knowing the patient and facilitating well-being was a crucial part of competence in weaning and opened up for establishing trust and confidence, which were necessary to reach into the patients’ world and “pull” the patient back to life, to the “here and now”. This “pulling” was connected to “pushing” the patient further in the weaning process. A potential link between breathlessness and post-intensive care syndrome is an argument for patients’ own reports of breathing to form part of nursing interventions and follow up supporting the patients’ quest for meaning. To enhance the quality of care in MV and weaning, intensive care nurses have an important role in the interprofessional team in order to discuss, reflect and learn how to assess and respond to patients’ experiences of breathing

Health promotion among long-term ICU patients and their families.

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penalizedclr: an R package for penalized conditional logistic regression for integration of multiple omics layers

The matched case–control design, up until recently mostly pertinent to epidemiological studies, is becoming customary in biomedical applications as well. For instance, in omics studies, it is quite common to compare cancer and healthy tissue from the same patient. Furthermore, researchers today routinely collect data from various and variable sources that they wish to relate to the case–control status. This highlights the need to develop and implement statistical methods that can take these tendencies into account. We present an R package penalizedclr, that provides an implementation of the penalized conditional logistic regression model for analyzing matched case–control studies. It allows for different penalties for different blocks of covariates, and it is therefore particularly useful in the presence of multi-source omics data. Both L1 and L2 penalties are implemented. Additionally, the package implements stability selection for variable selection in the considered regression model. The proposed method fills a gap in the available software for fitting high-dimensional conditional logistic regression models accounting for the matched design and block structure of predictors/features. The output consists of a set of selected variables that are significantly associated with case–control status. These variables can then be investigated in terms of functional interpretation or validation in further, more targeted studies

Time trends of perfluoroalkyl substances in blood in 30-year old Norwegian men and women in the period 1986–2007

Biomonitoring studies are helpful tools and can increase our knowledge on time trends in human blood concentrations of PFASs: how they relate to emission trends and the potential prenatal exposure for future generations. In this study, serum was sampled in cross-sections of men and women who were 30 years old in each of the years 1986, 1994, 2001, and 2007 in Northern Norway and analyzed for 23 PFASs. Differences in serum concentrations across sampling years were investigated graphically and with significance testing and compared with those observed in our previous longitudinal study using repeated individual measurements in older men in the same years. The results demonstrate overall increasing blood burdens of PFASs in men and women in reproductively active ages during 1986–2001 and decreases until 2007. However, longer chained PFASs were still increasing in 2007 indicating divergent time trends between the different PFASs, underlining the importance of continued biomonitoring. Comparisons between 30-year-old men and older men within the same population demonstrated variation in time trends in the exact same years, underlining that biomonitoring studies must regard historic exposures and birth cohort effects

Professionals' narratives of interactions with patients' families in intensive care

Background: ICU patients’ family members are in a new, uncertain, and vulnerable situation due to the patient’s critical illness and complete dependence on the ICU nurses and physicians. Family members’ feeling of being cared for is closely linked to clinicians’ attitudes and behavior. Aim: To explore ICU nurses’ and physicians’ bedside interaction with critically ill ICU patients´ families and discuss this in light of the ethics of care. Research design: A qualitative study using participant observation, focus groups, and thematic narrative analysis. Participants and research context: Data were gathered from July 2017 to August 2019, in four ICUs in Norway through 270 h of fieldwork and seven focus groups with ICU nurses and physicians. Ethical considerations: The Regional Committee for Medical and Health Research Ethics and the Norwegian Centre for Research Data approved the study. Findings: Quality of ICU family care depends on nurses’ and physicians’ attitudes, behavior, and personality traits. Three main themes were identified: being attentive, an active approach, and degree of tolerance. Discussion: The findings are discussed in light of the ethics of care and empirical research from the intensive care environment. Conclusions: This study shows that attentive, active, and tolerant clinicians represent a culture of ethical care that gives families greater freedom of action and active participation in patient care. Clinicians must not bear sole responsibility for this culture; it must have a firm basis in the hospital and ICU and be established through training, interprofessional reflection, and support of clinicians

‘I want to get back!’ A qualitative study of long-term critically ill patients’ inner strength and willpower : Back home after long-term intensive care

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Årsaker til forsinkelser ved elektive operasjoner: En prospektiv studie

Forsinkelser og strykninger under elektive operasjoner hindrer optimal drift og kan være en påkjenning for pasienter. Målet med studien var å identifisere og beskrive de faktiske årsaker til forsinkelser ved elektive operasjoner, samt omfang, varighet og andre kjennetegn ved slike forsinkelser. Studien har et flermetodisk prospektivt studiedesign. I en periode på to måneder ble alle elektronisk registrerte forsinkelser fulgt opp med strukturerte intervju. I løpet av studieperioden ble halvparten av elektive operasjoner registrert med en eller flere forsinkelser (N = 402). Informantene anga 60 ulike rotårsaker som en forklaring på forsinkelsene. I 72% av alle forsinkelser var årsaken knyttet til organisering/administrering av operasjonsplanleggingen. Forsinkelser ved elektive operasjoner skyldes i stor grad utilstrekkelig planlegging og organisering. Mer presis planlegging, informasjonsutveksling og forbedret dataverktøy kan redusere forsinkelser ved elektive operasjoner. Causes of delays in elective surgery: A prospective study Abstract Delays and cancellations in elective surgery prevent optimal services and can be stressful for patients. This study aimed to identify and describe the actual causes of delays in elective surgery, and the extent, duration and other characteristics of these delays. The study has a multi-method prospective study design. For two months, all electronically recorded delays in a Norwegian hospital were followed up with structured interviews to identify their true causes. Half of the elective surgeries recorded had one or more delays (N = 402). The delays had 60 different root causes; using qualitative content analysis, these were interpreted into 13 subcategories and four main categories, namely patient-related (17%), staff-related (10%), related to surgical ward/equipment (2%) or organizational (71%). Most delays were due to poor planning and organization of surgery. The study indicates that more precise planning, better information exchange and an improved electronic tool can reduce delays in elective surgery. &nbsp

Combined Lifestyle Behaviors and the Incidence of Common Cancer Types in the Norwegian Women and Cancer Study (NOWAC)

Introduction: Only a small number of studies have examined the impact of combined lifestyle behaviors on cancer incidence, and never in a Norwegian population. Purpose: To examine linear and nonlinear associations of combined lifestyle factors, assessed through a healthy lifestyle index (HLI), with the incidence of postmenopausal breast, colorectal, lung, postmenopausal endometrial, postmenopausal ovarian, pancreatic, and kidney cancer among women in Norway. Methods: This prospective study included 96,869 women enrolled in the Norwegian Women and Cancer (NOWAC) cohort. Baseline information on lifestyle factors was collected between 1996 and 2004. The HLI was constructed from five lifestyle factors: physical activity level, body mass index, smoking, alcohol consumption, and diet. Each factor contributed 0 to 4 points to the HLI score, which ranged from 0 to 20, with higher scores representing a healthier lifestyle. Multiple imputation was used to handle missing data. Cox proportional hazard regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). Restricted cubic splines were used to examine nonlinearity in the associations. Results: The HRs for a one-point increment on the HLI score were 0.97 (95% CI: 0.96– 0.98) for postmenopausal breast cancer, 0.98 (0.96– 1.00) for colorectal cancer, 0.86 (0.84– 0.87) for lung cancer, 0.93 (0.91– 0.95) for postmenopausal endometrial cancer, 0.99 (0.96– 1.02) for postmenopausal ovarian cancer, 0.92 (0.89– 0.95) for pancreatic cancer, and 0.94 (0.91– 0.97) for kidney cancer. Nonlinearity was observed for the inverse associations between HLI score and the incidence of lung cancer and postmenopausal breast cancer. Conclusion: Based on our results, healthier lifestyle, as assessed by the HLI score, was associated with lower incidence of postmenopausal breast, colorectal, lung, postmenopausal endometrial, pancreatic, and kidney cancer among women, although the magnitude and linearity varied. Adoption of healthier lifestyle behaviors should be a public health priority to reduce the cancer burden among Norwegian women

Assessing the relationship between perfluoroalkyl substances, thyroid hormones and binding proteins in pregnant women; a longitudinal mixed effects approach

Accepted manuscript version. Published version available at https://doi.org/10.1016/j.envint.2015.01.007. Accepted manuscript version, licensed CC BY-NC-ND 4.0.The mechanisms involved in thyroid homeostasis are complex, and perfluoroalkyl substances (PFASs) have been indicated to interfere at several levels in this endocrine system. Disruption of the maternal thyroid homeostasis during early pregnancy is of particular concern, where subclinical changes in maternal thyroid hormones (THs) may affect embryonic and foetal development. The present study investigated associations between THs, thyroid binding proteins (TH-BPs) and PFAS concentrations in pregnant women from Northern Norway. Women participating in The Northern Norway Mother-and-Child contaminant Cohort Study (MISA) donated a blood sample at three visits related to their pregnancy and postpartum period (during the second trimester, 3 days and 6 weeks after delivery) in the period 2007–2009. Participants were assigned to quartiles according to PFAS concentrations during the second trimester and mixed effects linear models were used to investigate potential associations between PFASs and repeated measurements of THs, TH-BPs, thyroxin binding capacity and thyroid peroxidase antibodies (anti-TPOs). Women within the highest perfluorooctane sulfonate (PFOS) quartile had 24% higher mean concentrations of thyroid stimulating hormone (TSH) compared to the first quartile at all sampling points. Women within the highest quartiles of perfluorodecanoate (PFDA) had 4% lower mean concentrations of triiodothyronine (T3) and women within the highest quartile of perfluoroundecanoate (PFUnDA) had 3% lower mean concentrations of free triiodothyronine (FT3). Further, the difference in concentrations and the changes between three time points were the same for the PFAS quartiles. Thyroxin binding capacity was associated with all the THs and TH-BPs, and was selected as a holistic adjustment for individual changes in TH homeostasis during pregnancy. Finally, adjusting for maternal iodine status did not influence the model predictions. Findings in the present study suggest modifications of TH homeostasis by PFASs in a background exposed maternal population. The variation in levels of THs between PFAS quartiles was within normal reference ranges and may not be of clinical significance in the pregnant woman. However, subtle individual changes in maternal THs may have significant consequences for foetal health

Persistent Organic Pollutants and the Association with Maternal and Infant Thyroid Homeostasis: A Multipollutant Assessment

Source: doi: 10.1289/EHP152.Reproduced with permission from Environmental Health Perspectives.Background:Disruption of thyroid homeostasis has been indicated in human studies targeting effects of persistent organic pollutants (POPs). Influence on the maternal thyroid system by POPs is of special interest during pregnancy because such effects could impair infant thyroid homeostasis. Objectives:We investigated the association between POPs and thyroid-stimulating hormone (TSH) and thyroid hormones (THs) in mother and child pairs from the Northern Norway Motherand- Child Contaminant Cohort Study (MISA). Methods:Nineteen POPs and 10 thyroid parameters were analyzed in serum from 391 pregnant women in their second trimester. In addition, TSH concentrations in heel-prick samples from the infants were analyzed by the Norwegian Newborn Screening program. Association studies with a multipollutant approach were performed using multivariate analyses; partial least squares (PLS) regression, hierarchical clustering, and principal component analysis (PCA). Results:Several POPs were significantly associated with TSH and THs: a) PFOS was positively associated with TSH; b) PCBs, HCB, and nonachlors were inversely associated with T3, T4, and FT4; and, c) PFDA and PFUnDA were inversely associated with T3 and FT3. After mutual adjustments for the other contaminants, only PFDA and PFUnDA remained significantly associated with T3 and FT3, respectively. Infants born to mothers within the highest TSH quartile had 10% higher mean concentrations of TSH compared with children born to mothers in the lowest TSH quartile. Conclusion:The present results suggest that background exposures to POPs can alter maternal thyroid homeostasis. This research contributes to the understanding of multipollutant exposures using multivariate statistical approaches and highlights the complexity of investigating environmental concentrations and mixtures in regard to maternal and infant thyroid function