Deaths Among Adult Patients with Hypopituitarism: Hypocortisolism During Acute Stress, and De Novo Malignant Brain Tumors Contribute to an Increased Mortality.

Context:Patients with hypopituitarism have an increased standardized mortality rate. The basis for this has not been fully clarified.Objective:To investigate in detail the cause of death in a large cohort of patients with hypopituitarism subjected to long-term follow-up.Design and Methods:All-cause and cause-specific mortality in 1286 Swedish patients with hypopituitarism prospectively monitored in KIMS (Pfizer International Metabolic Database) 1995-2009 were compared to general population data in the Swedish National Cause of Death Registry. In addition, events reported in KIMS, medical records, and postmortem reports were reviewed.Main Outcome Measures:Standardized mortality ratios (SMR) were calculated, with stratification for gender, attained age, and calendar year during follow-up.Results:An excess mortality was found, 120 deaths vs 84.3 expected, SMR 1.42 (95% confidence interval: 1.18-1.70). Infections, brain cancer, and sudden death were associated with significantly increased SMRs (6.32, 9.40, and 4.10, respectively). Fifteen patients, all ACTH-deficient, died from infections. Eight of these patients were considered to be in a state of adrenal crisis in connection with death (medical reports and post-mortem examinations). Another 8 patients died from de novo malignant brain tumors, 6 of which had had a benign pituitary lesion at baseline. Six of these 8 subjects had received prior radiation therapy.Conclusion:Two important causes of excess mortality were identified: first, adrenal crisis in response to acute stress and intercurrent illness; second, increased risk of a late appearance of de novo malignant brain tumors in patients who previously received radiotherapy. Both of these causes may be in part preventable by changes in the management of pituitary disease

Improved Cortisol Exposure-Time Profile and Outcome in Patients with Adrenal Insufficiency: A Prospective Randomized Trial of a Novel Hydrocortisone Dual-Release Formulation.

Context:Patients with treated adrenal insufficiency (AI) have increased morbidity and mortality rate. Our goal was to improve outcome by developing a once-daily (OD) oral hydrocortisone dual-release tablet with a more physiological exposure-time cortisol profile.Objective:The aim was to compare pharmacokinetics and metabolic outcome between OD and the same daily dose of thrice-daily (TID) dose of conventional hydrocortisone tablets.Design and Setting:We conducted an open, randomized, two-period, 12-wk crossover multicenter trial with a 24-wk extension at five university hospital centers.Patients:The trial enrolled 64 adults with primary AI; 11 had concomitant diabetes mellitus (DM).Intervention:The same daily dose of hydrocortisone was administered as OD dual-release or TID.Main Outcome Measure:We evaluated cortisol pharmacokinetics.Results:Compared with conventional TID, OD provided a sustained serum cortisol profile 0-4 h after the morning intake and reduced the late afternoon and the 24-h cortisol exposure. The mean weight (difference = -0.7 kg, P = 0.005), systolic blood pressure (difference = -5.5 mm Hg, P = 0.0001) and diastolic blood pressure (difference: -2.3 mm Hg; P = 0.03), and glycated hemoglobin (absolute difference = -0.1%, P = 0.0006) were all reduced after OD compared with TID at 12 wk. Compared with TID, a reduction in glycated hemoglobin by 0.6% was observed in patients with concomitant DM during OD (P = 0.004).Conclusion:The OD dual-release tablet provided a more circadian-based serum cortisol profile. Reduced body weight, reduced blood pressure, and improved glucose metabolism were observed during OD treatment. In particular, glucose metabolism improved in patients with concomitant DM

The Fluorescence Detector of the Pierre Auger Observatory

The Pierre Auger Observatory is a hybrid detector for ultra-high energy cosmic rays. It combines a surface array to measure secondary particles at ground level together with a fluorescence detector to measure the development of air showers in the atmosphere above the array. The fluorescence detector comprises 24 large telescopes specialized for measuring the nitrogen fluorescence caused by charged particles of cosmic ray air showers. In this paper we describe the components of the fluorescence detector including its optical system, the design of the camera, the electronics, and the systems for relative and absolute calibration. We also discuss the operation and the monitoring of the detector. Finally, we evaluate the detector performance and precision of shower reconstructions.Comment: 53 pages. Submitted to Nuclear Instruments and Methods in Physics Research Section

Particle-induced pulmonary acute phase response correlates with neutrophil influx linking inhaled particles and cardiovascular risk

BACKGROUND: Particulate air pollution is associated with cardiovascular disease. Acute phase response is causally linked to cardiovascular disease. Here, we propose that particle-induced pulmonary acute phase response provides an underlying mechanism for particle-induced cardiovascular risk. METHODS: We analysed the mRNA expression of Serum Amyloid A (Saa3) in lung tissue from female C57BL/6J mice exposed to different particles including nanomaterials (carbon black and titanium dioxide nanoparticles, multi- and single walled carbon nanotubes), diesel exhaust particles and airborne dust collected at a biofuel plant. Mice were exposed to single or multiple doses of particles by inhalation or intratracheal instillation and pulmonary mRNA expression of Saa3 was determined at different time points of up to 4 weeks after exposure. Also hepatic mRNA expression of Saa3, SAA3 protein levels in broncheoalveolar lavage fluid and in plasma and high density lipoprotein levels in plasma were determined in mice exposed to multiwalled carbon nanotubes. RESULTS: Pulmonary exposure to particles strongly increased Saa3 mRNA levels in lung tissue and elevated SAA3 protein levels in broncheoalveolar lavage fluid and plasma, whereas hepatic Saa3 levels were much less affected. Pulmonary Saa3 expression correlated with the number of neutrophils in BAL across different dosing regimens, doses and time points. CONCLUSIONS: Pulmonary acute phase response may constitute a direct link between particle inhalation and risk of cardiovascular disease. We propose that the particle-induced pulmonary acute phase response may predict risk for cardiovascular disease

Flexibilitet i affärssystem : Påverkan på verksamhet och användare

Flexibla affärssystem är ett begrepp som börjar synas mer och mer i tidskrifter. Detta begrepp belyses utifrån en litteraturstudie. Dessutom görs intervjuer på både affärssystem­leverantören Agresso och undersökningsföretaget Stena Fastigheter som använder systemet Agresso Business World. Syftet är att undersöka egenskapen flexibilitet i ett affärssystem som möjliggör att användarna skall kunna arbeta med anpassning efter verksamhetens behov. Det finns inte mycket forskat kring just flexibla affärssystem men det som återfinns är att flexibiliteten kan bestå av teknisk flexibilitet, dvs. att kunna öka eller minska systemet om antalet transaktioner eller användare förändras. Dessutom finns det funktionell flexibilitet, dvs. att inte behöva använda alltför mycket ansträngning, tid eller pengar för att kunna förändra affärssystemet. Anpassningar i affärssystemet handlar om att göra förändringar så att standardsystem och verksamhet liknar varandra på ett optimalt sätt. Att skjuta verksamhet och system mot varandra är det som rekommenderas till skillnad från att helt anpassa sig efter systemet eller efter verksamheten. Det sistnämnda kan möjliggöras om verksamheten väljer att bygga ett egenutvecklat affärssystem. Ett flexibelt affärssystem kännetecknas av att det är lätt att anpassa och att verksamheten kan anpassa systemet gentemot verksamheten både vid implementationen men även löpande under den vanliga driften. Dessutom bör systemet ge användarna möjligheten att bestämma om de själva vill utföra det arbetet eller om de vill lägga ut det på antingen IT-avdelningen eller IT-leverantören. Till sist kännetecknas ett flexibelt affärssystem av att utdatan, dvs. rapporter, skall kunna göras på en mängd olika sätt och utseenden, allt efter verksamhetens behov. Det flexibla affärssystemet påverkar användarorganisationens arbete med anpassningar genom att det krävs att de tänkt igenom vilken struktur som skall läggas in i systemet för att passa både nuläge och framtid. Det krävs också att användarna utbildat sig ordentligt i systemet om de själva skall utföra kommande anpassningsarbeten

Osastonhoitajien kokemukset saamastaan tiedosta ja tuesta sekä toiminnan muutoksen johtamisesta Terveyskylän digihoitopolun käyttöönotossa: laadullinen tutkimus

Digitalisaatio mahdollistaa terveydenhuollon uudistumisen. Digitaalisten palveluiden käyttöönotossa tarvitaan muutoksia organisaation sisäisiin rakenteisiin ja työprosesseihin. Johtajilla on merkittävä rooli digitaalisen palveluiden käyttöönoton tukemisessa ja uusien toimintamallien juurruttamisessa osaksi arkea. Digitalisaatio muuttaa myös johtajuutta ja johtajien käyttäytymistä. Johtajat tarvitsevat digitalisaation hyödyntämiseen liittyvää osaamista. Lisäksi he tarvitsevat tukea ja koulutusta sähköisten palveluiden käyttöönottoon. Tämän laadullisen tutkimuksen tarkoituksena oli kuvailla osastonhoitajien kokemuksia saamastaan tiedosta ja tuesta toiminnan muutoksen johtamisessa sekä toiminnan muutoksen johtamiseen vaikuttaneista tekijöistä Terveyskylän digihoitopolun käyttöönoton yhteydessä. Digihoitopolku on verkkopalvelu, jolla voidaan korvata tai täydentää perinteisiä terveydenhuollon käyntejä. Tutkimusaineisto kerättiin teemahaastattelulla yhden yliopistosairaalan osastonhoitajilta (n=6). Aineisto analysoitiin sisällönanalyysillä. Osastonhoitajat kokivat saaneensa verkostoiltaan tukea, tietoa digihoitopolun käyttöönotosta ja toiminnan muutoksesta sekä konkreettista tukea kehittämiseen. Toisaalta saadussa tiedossa ja tuessa koettiin olleen puutteita ja haasteita kehittämisprosessin aikana. Käyttöönottoon liittyvää toiminnan muutoksen johtamista edistivät resursoinnin ja rahoituksen toteutuminen, positiivinen asenne kehittämiseen ja osaamisen kartuttaminen, tavoitteellisuus kehittämisprosessissa, osallistaminen ja yhteiskehittäminen sekä verkostoilta saatu tuki ja sähköisten palveluiden aktiivinen käyttöönotto. Muutoksen johtamista haastoivat resursointi ja aikataulut, muutosvastarinta, toiminnan muutokset, puutteet tuessa ja digiosaamisessa sekä tietojärjestelmän tekniikka. Osastonhoitajat saavat tietoa ja tukea toiminnan muutoksen johtamiseen, mutta tiedon tulee olla esimiehille suunnattua. Ylemmän johdon tukea tarvitaan etenkin tavoitteiden asetteluun ja digihoitopolun hyötyjen konkretisoimiseen. Digihoitopolun käyttöönotossa onnistuneeseen toiminnan muutokseen vaaditaan riittävät aika- ja henkilöresurssit. Tutkimuksella saatua tietoa voidaan hyödyntää digihoitopolkujen sekä muiden sähköisten palveluiden kehittämisessä, käyttöönotoissa ja toiminnan muutoksen johtamisessa sosiaali- ja terveydenhuollossa sekä esimiehille tarkoitettujen koulutusten suunnittelussa. Digitalisation enables the reform of healthcare. The implementation of digital services requires changes in the internal structures and work processes within the organisation. Leaders have a key role in supporting the implementation of digital services and in making new operational models part of everyday practice. Digitalisation also changes leadership and the behaviour of leaders. Leaders need competence related to the utilisation of digitalisation. In addition, they need support and education on the implementation of digital services. The purpose of this qualitative study was to describe head nurses’ experiences of the information and support they have received on leading operational change and the factors affecting the management of operational change in connection with the implementation of Health Village’s digital care pathways. Digital care pathways are a web-based service that can be used to replace or complement traditional healthcare visits. The data were gathered through a thematic interview with the head nurses of one university hospital (n = 6). The data were analysed using content analysis. The head nurses felt they had received support and information from their networks about the implementation of the digital care pathway and operational change as well as concrete support for development. On the other hand, there were perceived shortcomings and challenges in the knowledge and support received during the development process. Management of the operational change was promoted by realisation of resourcing and funding, a positive attitude towards development and knowledge accrual, a goal-oriented development process, inclusion and co-development, as well as support received from networks and active deployment of digital services. Factors that challenged the management of the operational change included resourcing and scheduling, resistance to change, operational change, shortcomings in support and digital competence, and technical issues of the information system. Head nurses receive knowledge and support to manage the operational change, but the information should be directed at supervisors. Higher management support is needed, especially for setting goals and concretising the benefits of the digital care pathway. For successful operational change, the implementation of the digital care pathways requires sufficient time and human resources. The information obtained in the study can be utilised in the development and implementation of digital care pathways and other e-services and in leading the operational change in social and health care, and in planning education and training aimed at superiors

A digital care pathway to access healthcare without time and place restrictions

Abstract A digital care pathway is a secure digital service channel for patients in a care relationship with a specialized health care hospital in Finland. It is part of the Health Village portal built in co-operation with the Virtual Hospital project by five Finnish university hospitals led by Helsinki University Hospital. Health Village services make healthcare services available to all Finns regardless of place of residence and income level, thus improving the equality of citizens

Limited value of cabergoline in Cushing's disease: a prospective study of a 6-week treatment in 20 patients.

The role of cabergoline in Cushing's disease (CD) remains controversial. The experience is limited to case reports and few open studies that report the effects determined after ≥1 month of treatment. In prolactinomas and dopamine-responsive GH-secreting tumours, effects of cabergoline are seen within days or weeks. Here, we searched for short-term effects of cabergoline in CD