Venous thromboembolism and obstruction after pacemaker implantation. - A Prospective Study of 150 Consecutive Cardiac Pacing Device Implantations

Background: Pacemaker implantation (PMI) may predispose to venous thromboembolism (VTE) and obstruction (VO). This prospective study aimed at quantifying changes in venous calibers, and at determining the incidence of symptomatic and asymptomatic VTE/VO after PMI. Further goals included an assessment of the role of transesophageal echocardiography (TEE) in the diagnosis of lead-related central venous thrombi (CVT), and determination of predictors for VTE/VO. Methods: 150 (mean age 67; 61% male) consecutive patients with first PMI were enrolled and followed for 6 months. Contrast venography was performed at baseline and 6 months after PMI to measure venous diameters, and to detect stenosis, total occlusions and thrombi. TEE was conducted in 66 patients. Based on clinical suspicion, work-up for pulmonary embolism (PE) or acute deep vein thrombosis (DVT) were performed as needed. A total of 50 cases underwent longer-term (mean 2.4 years) follow-up venography. All cases with VTE/VO during the initial 6 months, and their matched controls, were selected for a case-control study focused on possible predictive role of laboratory and patient-related factors for the development of VTE/VO. Results: 10 (7 %) patients were found to have baseline venous abnormalities (e.g. 8 obstructions). Mean venous diameters diminished significantly during the first 6 months, but no further reduction occurred in late follow-up. New VO was discovered in 19 patients (14 %; 14 stenosis, 5 total occlusions; all asymptomatic). Small non-obstructive thrombi were found in 20/140 (14 %) 6-month venograms. TEE at 6 months disclosed CVT in 6 (9 %) patients. One (0.7 %) patient had acute symptomatic upper-extremity DVT, and PE was discovered in 5/150 (3.3 %) patients during the first 6 months with no further cases thereafter. At 6 months, the total number of cases with VTE/VO amounted to 47 (31.3 %). Additionally, the later 2-year venograms (n=50) disclosed 4 (8 %) total occlusions and 1 (2 %) stenosis. In the case-control study, no parameter was predictive of venous end-points as a single variable, but there appeared to be significant clustering of traditional VTE risk-factors among the cases. Laboratory parameters showed a definite acute hypercoagulative state induced by PMI, but its degree did not predict subsequent development of VTE/VO. Conclusions: This study shows that VTE/VO is relatively common after PMI with an overall incidence of at least 30 %. Although the majority of the lesions are asymptomatic and clinically benign, cases of PE were also encountered, and totally occluded veins may hamper future upgrading or replacement of pacing system. Venous complications seem difficult to prognosticate as firm predictors were not identified from a wide range of parameters analyzed in this study, although clustering of classic VTE risk factors may be a predisposing factor. Parameters related to implantation procedure or pacing systems and the severity of implantation-induced trauma did not emerge as predictors.

Rummet i vårdandets värld

This study is made in the context of basic research within the field ofcaring science. The aim is to make a theoretical and ontological investigation of what the space is in the world of caring. The basic proposition is that the space, as a fundamental dimension, has an impact on how the appreciation of one's mental health and suffering is shaped, and vice versa. The overall purpose is to develop a theoretical model of space from the caring science point of view andalso to offer an ideal concept of space to caring science. Guided by a theoretical horizon (Eriksson 1993, Eriksson 1995, Eriksson 2001) and methodological approach grounded in Gadamer's philosophic and existential hermeneutics a three-stage analysis and interpretation is conducted. The hermeneutic spiral of this investigation starts through a procedure in accordance with Eriksson's model (1997) of concept definition. The goal is to clarify the etymology of the concept as well as semantic differences between synonymous concepts, i.e. to identify the different extents of the concept of `space` (`rum`) in order to bring these closer for an exploration. The second phase is to analyse and interpret a sample of narratives in order to explicate the ontological nature and meaning of the space. The material used here is literary texts. The goal is to clarify the characteristics of the very inside of the space when it is shaped in relation to the human being in encountering suffering. In the third phase an interview study is taken place. The focus of the study is directed towards the phenomenon of space as it is known by a patient in a landscape of psychiatric care, i.e. what the space is in a contextual meaning. Then, a gradual hermeneutic understanding of the space is attempted by using theories from the field of caring science as well as additional theories from other disciplines. Metaphors are used as they are vivid and expressive tools for generating meaning. Different metaphoric space formations depict here a variety of purports that, although not quite the same, share extensive elements. Six metaphorically summarized entities of meaning emerged. The comprehensive form of space is pointed out as the Mobile-Immobile Room. Furthermore, the Standby, the Asylum, the Wall and the Place. In the further dialogue with the texts the understanding has deepened ontologically. The theoretical model ofthe space sums up the vertical, horizontal and the inward extent of deepness inthe movement of mental health. Three entities of ontological meaning have emerged as three significant rooms: the Common Land emerges as the ideal concept of mutual creation in the freedom of doing, being and becoming health. On the interpersonal level it means freedom, which includes sovereignty, choice and dignity of the human being. The Ice World signifies, ultimately, the space as a kind of frozenness of despair which "wallpapers" the person's entire being in the world in the drama of suffering. The Spiritual Home is shaped when the human being has acquired the very core of his/her inner and outer placeness as a kind of "at-homeness" and rootedness. Time is a central element and the inward extent of deepness of this trialectic space. Each of the metaphors is then the human being's unique, although even paradoxical, way of conceiving reality, and mastering spiritual suffering. They condense characteristic structures and patterns of dynamic scenery, which take place within the movement of health. The space encloses a contradictory spatiality constituted through the dynamic field of meaningfulness and meaninglessness. Anyway, it is not through a purging of these contradictions but through bringing them together in a drama of suffering that the space is shaped as ontologically good and meaningful in the world of caring.

Etätyön käyttöönoton haasteet - esimiesnäkökulma

Työ käsittelee etätyön käyttöönoton haasteita esimiestason näkökulmasta. Työssä käsitellään myös etätyön käyttöönottovaiheessa ilmeneviä paradoksimaisia tilanteita ja niiden ilmenemistä. Tutkimus on suoritettu kvalitatiivisena haastattelututkimuksena.

Breastfeeding preterm infant from the delivery ward via nicu to home

The aim of this study was to examine how to support breastfeeding of preterm infants immediately after birth in the delivery ward, during their hospital stay in a neonatal intensive care unit (NICU), and at home after hospital discharge. Specifically, the role of early physical contact, maternal breastfeeding attitude, and an internet-based peer support group were investigated. The delivery ward practices concerning the implementation of early physical contact between a mother and her infant admitted to a NICU were examined by a structured survey in two hospitals. An Internet-based, breastfeeding peer-support intervention for the mothers of preterm infants was developed and tested in a randomized controlled design with one year follow-up. The main outcomes were the duration of exclusive and overall breastfeeding, expressing milk, and maternal attitude. In addition, the perceptions of mothers of preterm infants were investigated by analyzing the peer-support group discussions with a qualitative approach. The implementation of early physical contact was different between the two hospitals studied and was based more on hospital routines than the physiological condition of the infant. Preterm infants, who were born before a gestational age (GA) of 32 weeks, were hardly ever allowed to have early contact with their mothers. Both, a higher GA and early physical contact predicted earlier initiation and increased frequency of breastfeeding in the NICU. A maternal breastfeeding-favorable attitude predicted increased frequency of breastfeeding in the NICU and also a longer duration of overall breastfeeding. The actual duration of breastfeeding was, however, shorter than the mothers intended in advance. The internet-based, peer-support intervention had no effect on the duration of breastfeeding, expressing milk, or maternal attitude. The participating mothers enjoyed the possibility of sharing their experiences of preterm infants with other mothers in similar situations. Some of the mothers also experienced being given useful advice for breastfeeding. Based on the mothers’ discussions, a process of breastfeeding preterm infants was created. This included some paradoxical elements in the NICU where, for example, breast milk was emphasized over breastfeeding and support in the hospital varied. Hospital discharge was a critical point, when the mothers faced breastfeeding in reality. Over time, the mothers assimilated their breastfeeding experience into part of being a mother. The care practices related to early physical contact in delivery wards need to be re-evaluated to allow more infants to have a moment with the mother. Maternal attitude could be screened prenatally and attitude-focused interventions developed. Breastfeeding support in the NICU should be standardized. Internet-based breastfeeding peer-support intervention was feasible but additional research is needed.