Premedikasjon til barn før kirurgiske inngrep - en kvalitativ studie av sykepleieres erfaringer

Sammendrag Bakgrunn og hensikt Barn som skal gjennomgå kirurgiske inngrep kan oppleve stress og engstelse i møte med et ukjent sykehusmiljø. I forkant av operasjoner kan barn få smertestillende og beroligende medikamenter, benevnt som premedikasjon. Målet med beroligende premedikasjon er å bidra til en trygg gjennomføring av narkose og forebygge postoperative komplikasjoner. Nyere forskning har imidlertid kritisert dagens praksis og peker på et behov for økt refleksjon rundt barnets beste i preoperativ sykepleie. Studiens hensikt er derfor å undersøke sykepleieres erfaringer med beroligende premedikasjon til barn under ti år, før et kirurgisk inngrep. Metode Studien har en kvalitativ metodetilnærming med semistrukturerte, individuelle intervjuer av fem sykepleiere på en barnekirurgisk avdeling i Norge. Inklusjonskriteriene for studien er autoriserte sykepleiere med minst ett års arbeid på avdelingen og erfaring fra preoperativt arbeid med barn. Datamaterialet er analysert inspirert av Braun & Clarkes fire steg i tematisk analyse. Resultat Resultatene fra studien er kategorisert i tre hovedkategorier som belyser sykepleieres erfaringer med beroligende premedikasjon før kirurgiske inngrep: 1.Sykepleiers tilpasninger til barnet med utgangspunkt i barnets alder og ytre påvirkningsfaktorer. 2.Barnets mulighet til mestring med fokus på hukommelsestap og opplevelse av kontroll. 3.Premedikasjon som rutine med refleksjoner rundt bruken av tvang mot barn og en rutinepreget praksis. Konklusjon Ifølge denne studien erfarer sykepleiere at barns behov i møte med premedikasjon varier med alder, modenhet og ytre påvirkningsfaktorer. Premedikasjon kan gjøre det lettere for barnet å håndtere det preoperative forløpet, men også svekke barnets opplevelse av kontroll og mestring. Sykepleierne opplever utfordringer ved administrering av premedikasjon, særlig ved bruk av tvang til de yngste barna. Funnene belyser ulike syn på rutinene ved premedikasjon, og indikerer et behov for refleksjon rundt dagens praksis.Abstract Background and purpose Children undergoing surgical procedures may experience stress and anxiety when faced with an unfamiliar hospital environment. Prior to surgery, they may receive analgesic and sedative medications, referred to as premedication. The purpose of sedative premedication is to support a safe induction of anaesthesia and prevent postoperative complications. However, recent research has criticised current practices and highlights a need for increased reflection on the best interests of the child in preoperative nursing care. This study aims to explore nurses' experiences with administering sedative premedication to children under the age of ten prior to surgical procedures. Method This study has a qualitative design based on semi-structured, individual interviews with five nurses at a paediatric surgical department in Norway. Inclusion criteria are licensed nurses with preoperative experience working with children and a minimum of one year of employment in the department. The data material was analysed inspired by Braun and Clarke’s four steps of thematic analysis. Results The findings are organized into three main categories that shed light on nurses' experiences with administering sedative premedication before surgery: 1.Nurses’ adaptions to the child, based on the child’s age and external influencing factors. 2.The child’s coping ability, focusing on memory loss and the experience of control. 3.Premedication as routine practice, including reflections on the use of coercion in care and standardised procedures. Conclusion According to this study, nurses experience that children's needs in relation to premedication vary with age, maturity, and external influencing factors. Premedication may help the child cope with the preoperative process but can also diminish the child’s sense of control and accomplishment. The nurses describe challenges in administering premedication, particularly when coercion is used with the youngest children. The findings highlight differing views on premedication routines and indicate a need for reflection on current practice

Rifting in heterogeneous lithosphere inferences from numerical modeling of the northern North Sea and the Oslo Graben.

Permian rifting and magmatism are widely documented across NW Europe. The different Permian basins often display contrasting structural styles and evolved in lithospheric domains with contrasting past evolution and contrasting thermotectonic ages. In particular, the Oslo Graben and the northern North Sea rift initiated in close areas of northern Europe. The Oslo Graben evolved in the cold and stable Precambrian lithosphere of Fennoscandia, whereas the northern North Sea rift took birth in freshly reworked Caledonian lithosphere. Huge volumes of magmatic rocks characterize the relatively narrow Oslo Graben. In contrast, little magmatism is documented for the wide northern North Sea rift. Differences in timing between both rifts are inferred but still debated. We present numerical thermomechanical models along a lithospheric E-W section that involves both the Oslo Graben and the northern North Sea area. Because the modeled section crosses the boundary between Caledonian and Proterozoic provinces, thermal and compositional heterogeneities are considered. As is suggested by various geophysical data sets, we also consider lithospheric thickness heterogeneities in the Precambrian lithosphere. Modeling results suggest that the northern North Sea was on top of "weak" lithosphere very sensitive to far-field stresses. Consequently, we suggest that rifting in the northern North Sea began as early as regional extension was effective (i.e., Late Carboniferous-Early Permian) and does not postdate the Oslo Graben as it is commonly assumed. Rifting in the "strong" Precambrian lithosphere is unexpected. Modeling results suggest that a pre-existing lithospheric thickness contrast within the Fennoscandian lithosphere favored rifting in the Oslo Graben

Craton Destruction 2:Evolution of Cratonic Lithosphere after a Rapid Keel Delamination Event

Cratonic lithosphere beneath the eastern North China Craton has undergone extensive destruction since early Jurassic times (approximately 190Ma). This is recorded in its episodic tectonic and magmatic history. In this time, its lithosphere changed thickness from approximately 200km to <60km. This change was associated with a peak time (approximately 120Ma) of lithospheric thinning and magmatism that was linked with high surface heat flow recorded in rift basins. We believe that these records are best explained by a two-stage evolutionary process. First, approximately 100km of cratonic keel underlying a weak midlithospheric discontinuity layer (approximately 80-100km) was rapidly removed in <10-20Ma. This keel delamination stage was followed by a protracted (approximately 50-100Ma) period of convective erosion and/or lithospheric extension that thinned the remaining lithosphere and continuously reworked the former cratonic lithospheric mantle. This study focuses on numerical exploration of the well-recorded second stage of the eastern North China Craton's lithospheric evolution. We find that (1) lithospheric mantle capped by thick crust can be locally replaced by deeper mantle material in 100Ma due to small-scale convective erosion; (2) asthenospheric upwelling and related extension can replace lithospheric mantle over horizontal length scales of 50-150km, and account for observed mushroom-shaped low-velocity structures; (3) modeling shows conditions that could lead to the multiple eastern North China Craton magmatic pulses between 190 and 115Ma that are associated with temporal and spatial changes in magma source petrology and a magmatic hiatus; and (4) a wet midlithospheric discontinuity layer provides a potential source material for on-craton magmatism

Craton Destruction 1:Cratonic Keel Delamination Along a Weak Midlithospheric Discontinuity Layer

Cratons are generally observed to retain thick (>180km) conductive keels for billions of years. However, some cratons have undergone keel removal, with well-documented examples being the eastern North China Craton (NCC) and the Wyoming Craton (WC). These keelless subregions appear to have kept a lithospheric bottom at 80-100-km depths. This is also the depth range where modern cratons, including the remaining portions of the NCC and the WC, have seismically visible midlithospheric discontinuity layers (MLDLs). MLDLs are proposed to be regions of preferential accumulation of metasomatic minerals and/or anomalously wet (>1,000ppm) peridotites, both of which would lead to a relatively weak rheology. We propose that the cratonic keels of the eastern NCC (ENCC) and the western WC (WWC) utilized this weak MLDL layer to delaminate from overlying lithosphere. We first explore this hypothesis with a lubrication-theory-based analytical model. This model suggests a close relationship between a cratonic keel's long-term stability and the strength of the MLDL's edge. We further test this prediction with less idealized 2-D numerical experiments which reveal that (a) dense lower keels beneath MLDL-bearing cratons can persist for billions of years as long as the MLDL's edges abut relatively cold and strong lithosphere; (b) MLDL edge failure can induce rapid intramantle lower keel delamination; and (c) the predicted rates of keel delamination along a 10-km-thick MLDL with a hydrous olivine or metasomatic mineral-dominated rheology are consistent with observations for the removal speeds of the WWC and the ENCC

Vanlig variabel immundefekt hos barn

Common variable immunodeficiency in children Background. Common variable immunodeficiency (CVID) is a primary immunodeficiency that shows considerable heterogeneity. Despite increased knowledge of the genetics of primary immunodeficiencies, the etiology of CVID remains largely unknown. CVID is the second most common primary immunodeficiency disorder after selective IgA deficiency (sIgAD). The majority of the patients presents with symptoms in early adulthood, but a minority of the patients presents with symptoms during childhood. Objective. To study the literature about CVID in children, focusing on clinical and immunological features and known genetic causes. This subgroup is considerably less elucidated in the literature than the adult CVID population. Methods. The project is based on reviews in books and on original and review articles in medical journals. The primary search was performed in PubMed/Medline with the keyword "common variable immunodeficiency", with "pediatric", "children" etc. used as additional keywords. Also, MeSH terms were used to standardize the searches. Due to the limited amount of hits, the search could not be limited any further. The references were written into a Reference Manager database. The project is primarily depending on data obtained from six paediatric studies. Results. The limited number of relevant studies and the low number of paediatric patients in these studies make conclusions somewhat difficult. The children received the CVID diagnosis around the age of 10 years, and the reported median diagnostic delay was a little less than 6 years. The paediatric studies showed no great difference between the sexes (58% males, 42% females, N=71). Only one gene mutation was reported in the studies, i.e. a ring chromosome 18. Developing CVID probably requires a combination of predisposing gene mutation and a trigger factor of unknown nature. The immunoglobulins varied considerably within and between the studies, although one study concluded that 29 of 32 children with CVID (91%) had significantly reduced serum levels of all immunoglobulin classes (IgG, IgA and IgM), and all 32 children had reduced serum IgG. All children with CVID had suffered from recurrent infections. Three studies (N=54) showed that 42 children (78%) had had pneumonia, 41 (76%) sinusitis and 37 (69%) otitis media. The frequency of allergies varied considerably between the studies, suggesting that different criteria have been used. One study showed that autoimmune diseases were present in 10 of 32 children with CVID (31%). The frequency of growth retardation also varied considerably between the studies (6-80%). All studies taken together showed growth retardation in 20 of 71 children (28%). Cancer is particularily reviewed in two studies. Lymphomas were dominating, and 8 of 42 children (19%) had malignancies. Bronchiectasis was altogether found in 30 of 87 children with CVID (34%), but the frequency varied from 12 to 90% between the studies. Several other disease associations were reported, but mostly as single cases. Splenomegaly was found in 20 of 42 children (48%) in two studies. One study (N=32) found enlarged lymph nodes (i.e. diameter >1 cm) locally in 15 children (47%) and diffusely in 10 children (31%). The same study found hepatomegaly in 9 children (28%). The treatment consists of immunoglobulin substitution therapy and antibiotic prophylaxis. The immunoglobulin substitution can be administered intravenously (IVIG) or subcutanously (SCIG). One study (N=32) showed that 27 children (84%) received IVIG, while 3 children (9%) received SCIG. However, SCIG is gaining popularity. The long-term survival is considerably reduced for CVID patients at all ages, compared to the normal population. The prognosis depends upon the clinical phenotype. Conclusion. CVID has been considerably less studied in children than in adults. The relevant reports are few, the number of patients described are small, and much of the findings reported are difficult to compare. It would be of considerable interest to perform a retrospective study on Norwegian paediatric CVID patients

Reduced forage access affects home range size and site fidelity of Svalbard reindeer (Rangifer tarandus platyrhynchus)

The Arctic is currently warming and this trend is expected to continue. This will lead to increased frequency and spatial extent of rain on snow events which cause ground ice to form. In this extreme and marginal environment, ground ice can have detrimental effects on the species living there. The objective of this study was to investigate how environmental conditions impact seasonal variation in the home ranges of individually marked Svalbard reindeer, in terms of home range size and site fidelity. To accomplish this, GPS data from female Svalbard reindeer in three valleys on Svalbard was combined with information on seasons and icing events. Ground icing was determined based on data from ground temperature loggers, precipitation data and field data on ice thickness. Included in the study were two winters with icing events, 2009/2010 and 2011/2012, and two without, 2010/2011 and 2012/2013. Home ranges were calculated with a 95 % fixed kernel estimator and site fidelity was measured as percent overlap of seasonal polygon home ranges. The reindeer had larger seasonal home ranges and displayed less site fidelity during the winter than during the summer. Winter home ranges were larger during years with icing events, compared to winters without. There was no correlation between calf status and home range size or site fidelity, or between age and site fidelity. Animals aged four to seven years had larger home ranges than younger (2-3 years) and older (8-11 years) reindeer. Svalbard reindeer seem to use small ranges as long as there is enough forage. They expand their home ranges in search for forage due to variations of food accessibility caused by extreme weather events. In a warming Arctic, this behavioral plasticity may be able to buffer the effects of increased rain on snow events on a small spatial scale

Redusert mattilgang påvirker størrelsen på leveområdet og graden av stedegenhet for Svalbardrein (Rangifer tarandus platyrhynchus).

The Arctic is currently warming and this trend is expected to continue. This will lead to increased frequency and spatial extent of rain on snow events which cause ground ice to form. In this extreme and marginal environment, ground ice can have detrimental effects on the species living there. The objective of this study was to investigate how environmental conditions impact seasonal variation in the home ranges of individually marked Svalbard reindeer, in terms of home range size and site fidelity. To accomplish this, GPS data from female Svalbard reindeer in three valleys on Svalbard was combined with information on seasons and icing events. Ground icing was determined based on data from ground temperature loggers, precipitation data and field data on ice thickness. Included in the study were two winters with icing events, 2009/2010 and 2011/2012, and two without, 2010/2011 and 2012/2013. Home ranges were calculated with a 95 % fixed kernel estimator and site fidelity was measured as percent overlap of seasonal polygon home ranges. The reindeer had larger seasonal home ranges and displayed less site fidelity during the winter than during the summer. Winter home ranges were larger during years with icing events, compared to winters without. There was no correlation between calf status and home range size or site fidelity, or between age and site fidelity. Animals aged four to seven years had larger home ranges than younger (2-3 years) and older (8-11 years) reindeer. Svalbard reindeer seem to use small ranges as long as there is enough forage. They expand their home ranges in search for forage due to variations of food accessibility caused by extreme weather events. In a warming Arctic, this behavioral plasticity may be able to buffer the effects of increased rain on snow events on a small spatial scale.M-N

Redusert mattilgang påvirker størrelsen på leveområdet og graden av stedegenhet for Svalbardrein (Rangifer tarandus platyrhynchus).

The Arctic is currently warming and this trend is expected to continue. This will lead to increased frequency and spatial extent of rain on snow events which cause ground ice to form. In this extreme and marginal environment, ground ice can have detrimental effects on the species living there. The objective of this study was to investigate how environmental conditions impact seasonal variation in the home ranges of individually marked Svalbard reindeer, in terms of home range size and site fidelity. To accomplish this, GPS data from female Svalbard reindeer in three valleys on Svalbard was combined with information on seasons and icing events. Ground icing was determined based on data from ground temperature loggers, precipitation data and field data on ice thickness. Included in the study were two winters with icing events, 2009/2010 and 2011/2012, and two without, 2010/2011 and 2012/2013. Home ranges were calculated with a 95 % fixed kernel estimator and site fidelity was measured as percent overlap of seasonal polygon home ranges. The reindeer had larger seasonal home ranges and displayed less site fidelity during the winter than during the summer. Winter home ranges were larger during years with icing events, compared to winters without. There was no correlation between calf status and home range size or site fidelity, or between age and site fidelity. Animals aged four to seven years had larger home ranges than younger (2-3 years) and older (8-11 years) reindeer. Svalbard reindeer seem to use small ranges as long as there is enough forage. They expand their home ranges in search for forage due to variations of food accessibility caused by extreme weather events. In a warming Arctic, this behavioral plasticity may be able to buffer the effects of increased rain on snow events on a small spatial scale.M-N