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 dialogical 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.     

Effects of prolonged surgical trauma on the extravascular lung water and central blood volume in the dog

Extravascular lung water (EVLW) and central blood volume (CBV) were measured in 13 dogs with a double-indicator dilution technique (dye-cold), the indicators being detected intravascularly. Animals in a control group (n = 5) were mechanically ventilated for 8-15 h after baseline measurements. Another group of animals (n = 8) were subjected to extensive lymph duct cannulations, including a thoracoabdominal incision, and the dogs were followed for 8 to 18 h postoperatively. All dogs (n = 13) then received a dose of oleic acid intravenously in order to create lung damage. A positive fluid balance was maintained throughout the experiment. Basal EVLW was 8.8 ml/kg (n = 13) (similar in both groups), and did not change significantly in either group before oleic acid. Basal CBV was 18.5 ml/kg (n = 13); it increased (P less than 0.05) in the control group and decreased (P less than 0.05) in the surgery group during a 8-15-h period. EVLW was doubled (P less than 0.001) and CBV decreased slightly 2 h after oleic acid administration. The lung damage was similar in both groups, and was accompanied by increased pulmonary vascular pressures and marked reductions in arterial oxygen tension and thoracic compliance. The findings suggest that an earlier proposed dog model for the simultaneous measurement of EVLW and lymph flow can be used in long-term studies on lung fluid balance.     

Output systems of the dorsal column nuclei in the cat

Numerous authors have demonstrated that the dorsal column nuclear complex (DCN) is functionally heterogeneous and has multiple terminal targets throughout the neuroaxis. In order to increase understanding of the functional significance of DCN's divergent connections, the present study used single and double light microscopic retrograde tracing strategies in the cat to characterize the location and morphology of DCN neurons that project to different portions of the diencephalon, rostral mesencephalon and spinal cord. These neuronal populations were then compared with those (previously reported from this and other laboratories) that project to the caudal mesencephalon, pons, inferior olive and cerebellum. When the results are considered together, a tentative picture of DCN emerges in which a population of clustered neurons that project exclusively to VPL form a core that is surrounded by and infiltrated with neurons projecting to other parts of the nervous system. Although the neuronal populations projecting to each of the different targets were individually separable anatomically by their location and/or morphological characteristics, previously reported physiological and other anatomical evidence permitted a preliminary grouping of these populations into 3 main systems. The first, a sensory tactile and kinesthetic 'cortical' system, consisted of 3 components: a double core of round, clustered medium-sized neurons (one each in the gracile and cuneate nuclei) and a variform rostral group projecting to the ventroposterolateral nucleus (VPL), a ventral group of unclustered large round neurons in the middle cuneate nucleus and a dense group of neurons in nucleus Z projecting to VPL's border with the ventrolateral nucleus (VPL/VL), and a group of mainly small-sized neurons located between the clusters of neurons or in the thin dorsal rim around the caudal and middle portions of the double cores and a populous, variform rostral group projecting indirectly (and possibly directly) to the posterior group through the intercollicular region of the tectum. The second, a sensorimotor 'cerebellar' system, consisted of multiple, subtly separable populations of neurons with different morphological characteristics all of which were located in different parts of the complex region that surrounds the cores on all sides. These neurons projected to restricted portions of interconnected targets within the zona incerta, tectum, pretectum, red nucleus, pontine grey, pontine raphe, inferior olive, and cerebellum.(ABSTRACT TRUNCATED AT 400 WORDS)     

Accuracy and precision of the computerized brain atlas programme for localization and quantification in positron emission tomography

The computerized brain atlas programme (CBA) provides a powerful tool for the anatomical analysis of functional images obtained with positron emission tomography (PET). With a repertoire of simple transformations, the data base of the CBA is first adapted to the anatomy of the subject's brain represented as a set of magnetic resonance (MR) or computed tomography (CT) images. After this, it is possible to spatially standardize (reformat) any set of tomographic images related to the subject, PET images, as well as CT and MR images, by applying the inverse atlas transformations. From these reformatted images, statistical images, such as average images and associated error images corresponding to different groups of subjects, may be produced. In all these images, anatomical structures can be localized using the atlas data base and the functional values can be evaluated quantitatively. The purpose of this study was to determine the spatial and quantitative accuracy and precision of the calculated regional mean values. Therefore, the CBA was applied to regional CBF (rCBF) measurements with [11C]fluoromethane and PET on 26 healthy male volunteers during rest and during three different physiological stimulation tasks. First, the spatial accuracy and precision of the reformation process were determined by measuring the spread of defined anatomical structures in the reformatted MR images of the subjects. Second, the mean global CBF and the mean rCBF in the average PET images were compared with the global CBF and rCBF in the original PET images. Our results demonstrate that the reformation process accurately transformed the individual brains of the subjects into the standard brain anatomy of the CBA. The precision of the reformation process had an SD of approximately 1 mm for the lateral dislocation of midline structures and approximately 2-3 mm for the dislocation of the inner and outer brain surfaces. The quantitative rCBF values of the original PET images were accurately represented in the reformatted PET images. Moreover, this study shows that the application of the CBA improves the analysis of functional PET images: (a) The average PET images had a low background noise [0.4 ml/100 g/min +/- 0.7 (SD)] compared to the mean rCBF changes specifically induced by physiological stimulation. (b) The reformatted PET images had a voxel volume of 10.9 mm3. Owing to this high sampling resolution, it was possible to differentiate the mean rCBF changes in adjacent activated fields such as the left motor hand area from the sensory hand area and the left premotor cortex.(ABSTRACT TRUNCATED AT 400 WORDS)     

Thoracic lymph drainage in the dog: Evaluation of a new model

A new model for selective sampling of thoracic lymph flow (TLF) and abdominal lymph flow (TDA) in the dog was assessed to ascertain whether there were extrathoracic contributions of lymph to the TLF. Inflating a right atrial balloon in 4 dogs and a left atrial balloon in 2 dogs indicated good separation between TLF and TDA. Data on total lymph protein and albumin clearance before and after oleic acid induced pulmonary oedema in an additional 5 dogs indicated that TLF and TDA drained two differing regions. Our data demonstrate that this lymph preparation provides a sample of thoracic lymph flow with no major extrathoracic lymph contamination. We also propose an alternative method to test for extrathoracic contributions to thoracic lymph, by the application of positive end-expiratory pressure, thereby replacing right atrial balloon inflation.     

Proliferative response of different exocrine pancreatic cell types to hormonal stimuli. I. Effects of long-term cerulein administration.

The trophic effect on the exocrine pancreas of the cholecystokinin analogue cerulein was studied in a long-term experiment (20 or 160 micrograms/kg/24 h for 14 days) in mice by measuring changes in pancreatic weight and protein, amylase, and DNA content. Further, the selective cell growth stimulation exerted by various doses of cerulein (4, 20, 54, 160 micrograms/kg/24 h) on different exocrine pancreatic cell types was studied by continuous administration of 3H-thymidine. In the first experiment animals given 20 micrograms/kg/24 h of cerulein had increased pancreatic weight and amylase and protein content, whereas the animals given the higher dose had unchanged weight and a less pronounced increase in amylase and protein content. The pancreatic DNA content was unaffected in the 20-micrograms group but was clearly decreased by the higher dose. In the second experiment a statistically significant increase over controls was found in the fraction of labeled ductal cells when 20, 54, and 160 micrograms of cerulein was administered. However, in the acinar cell population an increase was measured only in the 160-micrograms group. A tendency to nadir in cell labeling was observed in both acinar and ductal cell groups at less stimulation. Labeling of centroacinar cells increased in all cerulein-treated groups. The results show that all cell types of the exocrine pancreas can be forced into proliferation by the cholecystokinin analogue used and that there is preferential cell growth stimulation in the ductal and centroacinar cell populations.     

The projection to the mesencephalon from the sensory trigeminal nuclei. An anatomical study in the cat

The terminal areas and the cells of origin of the projection from the sensory trigeminal nuclei to the mesencephalon were investigated, using the method of anterograde and retrograde transport of horseradish peroxidase or wheat germ agglutinin-horseradish peroxidase conjugate. Injection of tracer into the nucleus interpolaris or nucleus oralis (in the latter cases with involvement of the nucleus principalis) resulted in dense anterograde labeling in the deep and intermediate gray layers of the contralateral superior colliculus, extending throughout the rostrocaudal extent of the colliculus with the exception of its caudalmost part, which was not labeled. Minor projections to the intercollicular nucleus, posterior pretectal nucleus and nucleus of Darkschewitsch were found. Injection of tracer into the nucleus caudalis yielded a completely different result; terminal labeling in the midbrain was now present only in the periaqueductal gray matter, in its rostral and middle parts. The retrograde labeling observed after injection of tracer into the midbrain terminal areas showed that the cells of origin were located mainly in the alaminar spinal trigeminal nucleus, and the highest density of labeled neurons was found in the rostral part (subnucleus y) of the nucleus oralis. The retrograde labeling in the nucleus principalis was very sparse and almost exclusively involved peripherally located neurons. In the nucleus caudalis the overwhelming majority of the retrogradely labeled neurons were situated in its marginal layer. The functional implications of the above observations are discussed in relation to the findings in previous studies of the projections from the dorsal column nuclei and spinal cord to the midbrain. The combined results suggest that the trigeminal projections to the superior colliculus may be involved in the mechanisms of orientational behavior. The observation that the projection to the periaqueductal gray matter originates in the marginal layer suggests that it transmits information related to noxious stimuli.