Towards interprofessional networking in medication management of the aged: current challenges and potential solutions in Finland

Objective: The Finnish Medicines Agency (Fimea) initiated a programme in 2012 for enhancing interprofessional networking in the medication management of the aged. The goal is to develop national guidelines for interprofessional collaboration with respect to medication management. This study aims to explore the challenges and potential solutions experienced by existing health care teams in managing medication of the aged: (1) at the individual and team level (micro level), (2) organisational level (meso level) and (3) structural level (macro level).

Design: Group discussions (n?=?10), pair (n?=?3) and individual interviews (n?=?2). Abductive content analysis combining data and theory was applied. Networking was used as a theoretical framework.

Setting: Meetings (n?=?15) organised by Fimea in the formation phase of the interprofessional network in 2012.

Subjects: Health care professionals (n?=?55).

Main outcome measures: Challenges and solutions in the medication management of the aged at the micro, meso and macro levels.

Results: Challenges in interprofessional collaboration, problems with patient record systems, and the organisation of work and lack of resources were present at all the levels contributing to patients’ medication problems. Participants suggested multiple potential solutions to improve interprofessional collaboration, sharing of tasks and responsibilities, better exploitation of pharmaceutical knowledge and developing tools as being the most commonly mentioned.

Conclusions: Optimising medication use of the aged requires new systemic solutions within and between different system levels. The main challenges can be solved by clarifying responsibilities, enhancing communication and applying operational models that involve pharmacists and the use of information technology in medication management.

• KEY POINTS

• An interprofessional team approach has been suggested as a solution to promote rational medicine use among the aged.

• Fragmented health care system and lack of coordinated patient care are reasons for medication related problems of the aged.

• Challenges in the implementation of interprofessional collaboration in medication management appear in legislation, information systems, operational models and individuals’ attitudes.

• Optimising medications requires better interprofessional networking and new systemic solutions within and between macro, meso and micro levels.

     

Potential case of gynecomastia in mummified remains of an early modern period northern finnish vicar

We report possibly the oldest evidence of gynecomastia in mummified human remains. Computed tomography was performed on the mummified remains of an early 17th century Northern Finnish vicar. The examination of the scans revealed large bilateral subareolar irregular masses resembling female mammary glands. The nearly septuagenarian vicar appears to have had gynecomastia, as it is a common condition in elderly men, and is sometimes associated with obesity. Gynecomastia is the most likely explanation for these findings. Clin. Anat. 31:641–644, 2018. © 2018 Wiley Periodicals, Inc.     

No evidence that established type 2 diabetes susceptibility variants in the PPARG and KCNJ11 genes have pleiotropic effects on early growth

Aims/hypothesis The P12A variant in the PPARG gene and the E23K polymorphism in KCNJ11 are both known to influence individual predisposition to type 2 diabetes. If the effect of these variants on insulin secretion and action were to extend to an influence on early growth (which is largely mediated by insulin), it would offer an explanation for observed associations between low birthweight and subsequent diabetes. Since previous studies of the effects of these variants on early growth have been limited and conflicting, we examined these associations in a large, well-characterised birth cohort. Methods The P12A and E23K variants were genotyped in (respectively) 5,652 and 5,632 individuals from the Northern Finland Birth Cohort of 1966 and we sought associations with early growth phenotypes. Results Neither variant was associated with birthweight (P12A, p = 0.42; E23K, p = 0.44, additive models) or other measures of early growth. Although a previous report had suggested that the P12A effect on adult insulin sensitivity was restricted to small babies, we were unable to reproduce this finding (p = 0.40), nor did we confirm a previous report of an association with gestational age (p = 0.23). Conclusions/interpretation Despite a larger sample size than previous studies, we were unable to detect any effect of these variants on early growth. These findings do not support the notion that there are shared genetic determinants of low birthweight and adult diabetes. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

Quality of institutional care of older people as evaluated by nursing staff

Aims. The aim of this paper was to report on the quality of institutional nursing of older people as evaluated by nursing staff in 2001 and to compare the responses with those obtained in 1998. Background. The healthcare division of one Finnish city authorised an outside survey of long‐term geriatric care in the hospitals providing such care in 1998. Based on the results, recommendations concerning the development of care of older people were issued. A re‐survey was conducted in 2001, using the same criteria of quality assessment. Methods. A survey research method was used. All the seven institutions providing long‐term geriatric care, including a total of 53 wards, participated. In 1998, a total of 607 questionnaires was returned. The response percentage was 78·6%. In 2001, a total of 573 questionnaires was returned. The response percentage was 76·8%. Results. The staff considered their possibilities to help geriatric patients best in the domain of physical care and slightly less good in the domain of psychosocial care. The differences in staff estimates between the two years were very small. More than 90% of the respondents considered their knowledge of physical care adequate. The nursing staff's evaluations were roughly similar in 1998 and 2001. More than 98% of the respondents considered the helping of older people important or moderately important in the other subdomains except sexual expression. According to the nursing staff, intentional or unintentional negligence in care was more common than physically or psychically offensive conduct. Observations concerning maltreatment had increased from 1998 to 2001. The staff reported both physical and mental fatigue. Nevertheless, the nursing staff appeared to be quite content with their current workplaces. Relevance to clinical practice. The findings indicated that geriatric care mostly aims to respond to the physical needs of older people. Nursing should, therefore, be developed and improved because mere satisfaction of physical needs is not enough to guarantee a good quality of life for older people in long‐term institutional care.     

The history of ideas of Nordic midwives’ excursions from the early 19th century to the millennium

The midwifery art has emphasised the uniqueness of human beings throughout its Nordic history. The educated Nordic midwife has in the last decade celebrated several hundred years of memories. This article studies how the key ideas of the midwifery art and patterns of ideas become evident in the zeitgeist from the beginning of the 19th century to the millennium in the Nordic countries. The legacy and pattern of ideas of the art of midwifery are interpreted in relation to the texts of the selected historical sources and based on Ricoeur's phenomenological-hermeneutic approach to the text and further to the dedication of understanding and interpretation. The historical sources refer to unprinted primary sources from historical archives and printed secondary and tertiary sources. The patterns of ideas include a tripartite whole: the true cultivation of the head, the philosophy and aesthetics of the hand, the strength of the heart and the drive of calling. These ideas open for unique visions and attest to the evident in modern midwives. Today's midwives have academic training with examinations, and the education is based on scientific evidence. The midwife profession is authorised by the state and supervised by the authorities.     

Defective metabolic clearance of plasma arginine and ornithine in lysinuric protein intolerance

Fasting plasma lysine, arginine, and ornithine concentration is clearly statistically decreased in patients with lysinuric protein intolerance (LPI). In seven LPI patients and five reference subjects, one suffering from classic cystinuria, arginine and ornithine were infused intravenously at a stepwise-increased rate. Plasma steady-state concentration of the infused diamino acid was larger in LPI patients than in the reference subjects, although the patients lost more into the urine. The increase in plasma ornithine and urea concentration on arginine infusion was similar in both groups. Calculated metabolic clearance rates (MCR) of arginine and ornithine were clearly smaller in LPI patients than in the reference subjects. Infusion of lysine brought about a clear decrease in the MCR of arginine; this was similar in both groups of subjects. These findings suggest a defect in the transport of diamino acids into liver cells, such as has been earlier demonstrated in the renal tubuli. Such a general cellular transport defect of diamino acids would explain both basic characteristics of LPI: renal loss of diamino acids and slow urea synthesis.     

Pancreatic resections are not only safest but also most cost-effective when performed in a high-volume centre: A Finnish register study

BackgroundIt is not known whether the treatment costs of pancreatic surgery can be reduced by centralisation. The aim of this study was to analyse the impact of hospital volume on the short-term prognosis and costs in a nationwide study.MethodsThe National registry was searched for patients undergoing pancreatoduodenectomy (PD) in Finland between 2012 and 2014. Patient data was recorded up to ninety days postoperatively and Charlson comorbidity index (CCI) calculated. Complications were classified according to Clavien-Dindo. A CCI was calculated for each patient. The hospitals were categorized by yearly resection rate: high (≥20, HVC), medium (6–19, MVC) and low (≤5, LVC). Costs were calculated according to the 2012 billing list.ResultsThe study population comprised 466 patients. Demographics were similar in the HVC, MVC and LVC groups. Mortality was lower in the HVCs than in MVCs and LVCs at 30 days (0.8% vs. 8.8–12.9%; p < 0.01) and at 90 days (1.9% vs. 10.5–16.1%; p < 0.01). Hospital volume and CCI were significant factors for mortality in multivariate analysis. Median costs among all patients were lower in the HVC group than in the MVC/LVC groups (p = 0.019), among Clavien-Dindo class III (0.020), among patients over 75 years (p < 0.001) and among patients who survived over five days (p = 0.015).ConclusionsThirty- and 90-day mortality is 10 times lower when the patient is operated on in an HVC. The study shows that the median overall costs of surgical treatment are 82–88% of the median costs in lower volume centres.     

Tooth loss is associated with increased risk of gastric non-cardia adenocarcinoma in a cohort of Finnish smokers

Objective Tooth loss has been associated with upper gastrointestinal cancer in several studies, but only one previous study used prospectively collected data. The importance of confounding by Helicobacter pylori has not previously been addressed. The objective was to determine the association between tooth loss and upper gastrointestinal cancer in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study cohort and to determine the importance of potentially confounding dietary factors or H. pylori seropositivity. Material and methods A prospective cohort study with 29,124 subjects included 49 esophageal squamous cell carcinomas, 66 esophageal/gastric cardia adenocarcinomas, and 179 gastric non-cardia adenocarcinomas occurring between 1985 and 1999. Cox proportional hazards models adjusted for age and education were used to estimate hazard ratios (HRs) and 95% CIs. Odds ratios and 95% CIs were calculated with and without adjustment for H. pylori seropositivity in a nested case-control group to determine whether H. pylori confounded the association between tooth loss and gastric cancer. Results Tooth loss significantly increased the hazard ratio for gastric non-cardia cancer, the HR (95% CI) for edentulous subjects versus those with <10 teeth lost was 1.65 (1.09, 2.49, respectively). No statistically significant associations were found between tooth loss and esophageal squamous cell carcinoma or esophageal/gastric cardia adenocarcinoma. Confounding by dietary factors, tobacco smoking, or H. pylori did not explain these results. Conclusions Tooth loss was associated with increased risk of gastric non-cardia cancer, but not esophageal squamous cell carcinoma or esophageal/gastric cardia adenocarcinoma in this Finnish cohort.