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Normalising cancer

Why did you decide to write a book about this topic?

– I was driven to write this book, both scientifically and morally. The first version of the book was written in Norwegian with the title “Kreft er ikke smittsomt”. Science communication has always been important to me, and cancer is a complex topic that is not necessarily easy to talk about with children. Publishing this book with IARC/WHO during my time at NTNU fulfills the mission/vision of both organisations: “Cancer research for cancer prevention” and “Knowledge for a better world”.

Why do you think it is important that children of cancer patient have this book written for them?

– I was born and raised in a mining town in Northern Ontario in Canada. The community I am from is riddled with cancer, not only from exposure to toxic mining practices, but also due to lifestyle. Cancer was, and continues to be, very common in my home town. Still, information for children and young people are lacking and it can be very difficult of parents, family members, teachers, etc. to speak with children about cancer.

– In addition to the story, I have included a Q&A section that is scientifically sound, but also gently written. Hopefully the story, including the Q&A will be helpful, not only for children to better understand cancer as a disease, but also to help children normalise any feelings of fear, anxiety, uncertainty that they may have when someone they love has been diagnosed with cancer and is undergoing treatment.  

You have donated all the proceeds to IARC/WHO, why them?

– As the specialized cancer agency of the World Health Organization, IARC is considered the world authority on cancer. Children and youth now have unprecedented access to information online. As adults we understand how challenging it is to decipher that information – not only because of the volume of information that is available, but also because it can be difficult to know which sources to trust. I strongly felt that publishing this book with the IARC/WHO logo would be of major service to the public. A source of information that is scientifically peer-reviewed for truth and validity. A source of information that children, youth, parents, family, teachers, librarians could trust.

As a scientist in academia, both my salary and my research is supported by public funds. This means that all of my research belongs to the public. As such, I felt very strongly that this book should be for the benefit of all, not only for my personal benefit.

A conversation-starter

What are your hopes for this book?

– Cancer is a scary word and in many ways, a black box. Even as adults, we have difficulty understanding cancer as a disease, cancer treatment, possible outcomes, and the role of genetics vs. the role of lifestyle and environment. During my PhD period I lost 3 close family members to cancer. You can see their names listed as a dedication in my dissertation. It is difficult for adults to face cancer and the possibly of death, I can only imagine how difficult it would be for a child to face these same facts.

My sincere hope is that families can use this book to start a conversation with children and navigate the very difficult topic of cancer.

– Although the book is fiction, it is also scientifically true. In fact, senior scientists from IARC/WHO peer-reviewed the book for scientific accuracy. We´ve even included a Q&A section at the back to touch on important issues that were not covered in the story. With 100% of proceeds from the sale of the book going to cancer education and training, I also hope that this grassroots effort will have a positive impact on the education and training of cancer researchers world-wide.

The process

Tricia Larose at the International Agency for Research on Cancer (IARC).

– As a scientist publishing scientific articles, book chapters, etc. we don´t often see the process behind the publication. We simply send it off for peer review and once accepted, we expect to see it published all neat and tidy on the page or in our download. There´s a lot of steps in between that I took for granted, but after A Checklist for Dad, I have a better understanding of the overall publishing process.

What was the writing process like for you?

Unlike scientific writing, my writing process for this book was emotionally driven. It was challenging to find a balance between writing a palatable story, and infusing facts around cancer genetics, diagnosis and treatment.

The process of working with an Editor who specialises in children´s book and inclusivity was very helpful. This is my first children´s book so I needed some help. Although the story line remained largely unchanged, the nuance of language and timing was much improved with the help of my Editor

We understand that this is IARC/WHO´s first children´s book?

Yes. Once I decided to offer the book to IARC/WHO, which meant signing over my copyright and donating 100% of the proceeds from the sale of the book to the Education and Training Group at IARC/WHO, I had to be willing to adapt the text and story line so that it best represented the IARC/WHO mission and mandate.

 Can you tell us a bit about the illustrations in the book?

–  The book is wonderfully illustrated by French artist, Gwen Le Rest. It was amazing to see the story come to life on the page. It´s difficult to choose a favourite illustration, because there are so many that evoke strong emotions for various reasons. For example, the illustration when Ella gets a stomach ache and thinks she might have cancer just like her Dad

This was my first time working with an illustrator and Gwen was fantastic.

Will we see more of you as a literary author?

– A Checklist for Dad is my first published children´s book, and I hope to have it translated into other languages, including Norwegian. I also have more children´s books on the way. Stay tuned!

About the author
During her postdoctoral training (and writing of this book) Tricia Larose held a 2-year mandatory overseas research stay at the International Agency for Research on Cancer – the specialized cancer agency of the World Health Organization in Lyon, France. The last year of her postdoc was hosted by the K.G. Jebsen Center for Genetic Epidemiology at the Faculty of Medicine and Health Sciences, NTNU. You can follow Tricia on Twitter @TricLarose
The book is now available on Amazon, and 100% of the proceeds from the sale of this book go to the Education and Training Group at IARC/WHO.

Read more about her book project on Norwegian SciTech News.

Violence against women is a human rights violation with grave health consequences and crippling effects on women’s abilities to contribute to societal development. Furthermore, violence against women is a global phenomenon, but women in low-income countries suffer a disproportionate burden. Factors such as economic crisis, political instability and civil unrest amplifies the burden. This is the case in Nepal, where the second phase of the ADVANCE project (Addressing Domestic Violence in Pregnancy 2) is based. 

The ADVANCE project addresses one of the most common types of violence against women, domestic violence, which poses significant health risks to women and their unborn infants in pregnancy. Antenatal care presents an opportunity for women to access adequate assistance that may prevent pregnancy-related complications caused by violence and that can have long-standing effects on maternal and child health.

Antenatal care (ANC) presents a ‘window of opportunity’ to reduce the harmful health consequences of domestic violence as most women use ANC services in their lifetimes (Photo: iStock)

However, to date, evidence of the effectiveness of  interventions to address domestic violence in antenatal care contexts is limited and mainly obtained from studies conducted in high-income countries. Considerable knowledge gaps exist to inform antenatal care providers in identifying and assisting pregnant women living with domestic violence in low-income country settings.

The original phase of the ADVANCE project (Addressing Domestic Violence in Antenatal Care Environments) was funded by the Research Council of Norway from 2013-2018 to fill some of these gaps, in Nepal and Sri Lanka. The ADVANCE project team has now been awarded 11 million Norwegian kroner from the FRIPRO research programme of The Research Council of Norway for a second phase of the project (2020-2025) focused on research activities in Nepal. ADVANCE 2 builds on findings from the first ADVANCE studies, now with the aim of ensuring sustainable and evidence-based changes can be made to antenatal care in Nepal.

How can knowledge from high-income countries be contextually adapted to be relevant and useful in other settings? How can effective low-cost interventions be set in place? How will such interventions reach women in the most remote areas where all types of health services are limited? In contexts where few women living with domestic violence are able to leave the relationship, how can health providers assist in mitigating potential harms to women’s health during pregnancy? These are some of the research questions we will answer in the continuation of the ADVANCE project.

To date, the ADVANCE team has completed a pioneering assessment of the burden of domestic violence in pregnancy in Nepal. We found a substantial proportion (21%) of pregnant women reported the experience of domestic violence, as published in the Scandinavian Journal of Public Health in August 2017. Young age and low socioeconomic status were particular risk factors for experiencing domestic violence. Women who reported having their own income and the autonomy to use it were at significantly lower risk of domestic violence compared to women with no income. The study also found that few women had ever disclosed their experience of domestic violence to a health care provider or been asked about domestic violence by a health provider. This underlines the importance of integrating culturally-sensitive and systematic assessment of domestic violence into antenatal care in the future in Nepal.

Project leaders, Research Fellow Jennifer Infanti and Professor Berit Schei

With ADVANCE 2, our team is planning to improve the assessment instrument we developed for the prevalence study, and formally validate it. The assessment instrument is an adapted version of the Abuse Assessment Screen (AAS), a widely-used five-item instrument originally developed in the USA to detect violence against pregnant women. We have translated the instrument to Nepali language and developed an electronic method of data capture for it called a Colour-Coded Audio Computer-Assisted Self-Interview (C-ACASI). Women wear headphones connected to a tablet computer, listen to the questions read to them by a recorded voice through the headphones, and respond to the answers by pressing colour-coded options (for example, in our study, red = yes and green = no). This technology allows women to answer sensitive questions about domestic violence in privacy in otherwise busy antenatal care settings. Importantly, it also allows for the inclusion of participants with limited or no literacy. In Nepal, the female literacy rate is approximately 67%.

We have also carried out an extensive qualitative study with 41 men and 76 women in 12 focus group discussions in community settings to explore perceptions of domestic violence in pregnancy. This was published in Global Health Action in 2016. In this work, we learned that other events than those covered in the AAS could be classified as domestic violence in Nepal and have the potential for harmful effects on a woman’s pregnancy. The community members identified culturally-specific forms of DV such as mothers-in-law restricting or denying food to pregnant women; being forced to perform long days of heavy manual labour into late pregnancy; bullying, belittling, threats and psychological stress related to dowries; and psychological stress related to cultural preference, familial pressure and taunting to give birth to a son.

Again, ADVANCE 2 builds on this prior knowledge. In the new study, we will modify the AAS to ensure it captures culturally-relevant examples of domestic violence, particularly types of emotional abuse. Our aim is therefore to create the Nepalese Abuse Assessment Screen (N-AAS), which will then be formally validated in our two partner hospitals (Dhulikhel Hospital and Kathmandu Medical College).

Example of illustrations made by a Nepalese artist to explain possible safety measures to practice during pregnancy.

It is critical not only to identify pregnant women living with domestic violence but also to provide them with assistance. In our prior work, we assessed the impact of a safety-promoting intervention delivered on an antenatal care ward at Kathmandu Medical College, in a cohort study. Pregnant women between 12-28 weeks gestation were recruited to the study at their regular antenatal care appointments at the hospital. They were educated about safety measures by a nurse or researcher using a pictorial flipchart that we developed in a teaching session lasting for a maximum of 30 minutes. The flipchart was based on a standardised safety behaviour checklist, originally created in a high-income country setting. We adapted the checklist to ensure the relevance of the safety behaviours for women in Nepal. The figure above is an example of the safety behaviours.

The findings of our study were promising, as published in the International Journal of Environmental Research and Public Health in 2020. We observed that the range of safety measures used by women increased from baseline to follow-up. However, the main weakness was the follow-up cohort study design as we were unable to compare the use of safety measures with other types of intervention. Therefore, in ADVANCE 2, we plan to test the intervention in a randomised controlled trial compared to standard care in both of our partner hospitals. This will expand the evidence-base on health sector interventions to address domestic violence in low-income country settings. The long-term goal is to integrate safety planning into standard antenatal care in Nepal.

The ADVANCE 2 study is led by Research Fellow Jennifer Infanti and Professor Berit Schei (Principal Investigator) at Department of Public Health and Nursing, NTNU. Our former PhD candidates from the original ADVANCE study, now NTNU graduates, will continue in key roles in the project’s second phase. Poonam Rishal is postdoctoral researcher for ADVANCE 2, based at Kathmandu Medical College and Teaching Hospital (KMC). Kunta Devi Pun is co-local Principal Investigator for ADVANCE 2, based at Dhulikhel Hospital-Kathmandu University School of Medical Sciences (KUSMS). Our other local Principal Investigators in Nepal are Sunil Kumar Joshi (KMC) and Rajendra Koju (DH-KUSMS). In Scandinavia, our partner institutions and/or supervisors for the ADVANCE 2 project include Katarina Swahnberg at Linnaeus University (Sweden), Mirjam Lukasse at University of South-Eastern Norway, and Lena Henriksen at Oslo Metropolitan University. Jacquelyn C. Campbell at Johns Hopkins School of Nursing (USA) is international advisor to the project team.

Vikram Singh Parmar, Ulrik Wisløff, Øyvind Sandbakk and Erney Mattsson at the Norwegian Embassy in New Delhi

By Vikram Singh Parmar, innovation leader, NTNU

Under the NTNU’s Strategic Program of Knowledge Based Innovation for the period 2018 – 2025, Dr. Vikram Singh Parmar, Innovation Leader from the Center for Elite Sports Research, INB and Center for Cardiac Research, ISB organized a trip to India on August 27th-30th, 2019. The Innovation Norway’s office of the Royal Norwegian Embassy, New Delhi hosted the delegation from NTNU. The delegation included Prof. Ulrik Wisløff from ISB, Prof. Øyvind Sandbakk from INB, and Prof. Erney Mattsson from ISB.

NTNU and Innovation Norway teamed up to organize a seminar on “Indo-Norwegian Seminar on Innovations in Elite Sports Medicine and Cardiovascular Surgery” with Indian sports organizations, universities, and hospitals.

The objective of the seminar was to learn from innovations in sports medicine and technology in Norway and how to leverage these in Indian sports, at national and international/Olympics levels. In addition to being very successful in elite sports, Norway has successfully used sports science and technology, both at a school, university and community level to promote health and wellness among Norwegians. How can this sports model be replicated and customized for Indian setting?

From the Indian side, we saw participation from the only Olympic gold medalist from India Mr. Abhinav Bindra who spoke about his experiences and need for better sports infrastructure to train Indian athletes and in general for Indian citizens. The Indian participants included representative from government and private sports organizations, universities interested in setting up sports driven educational programs.

From the Norwegian side, Prof. Wisløff presented work from CERG about the value of physical activity, cardiorespiratory fitness, and personal activity intelligence. He also shared evidence of beneficial effects of high intensity physical activity in health and disease.  Prof. Sandbakk presented work from SenTIF on how his group successfully combine world-class athlete support with high-quality research. He spoke about Olympic and Paralympic athletes and how exercise physiology, recovery optimization, and equipment optimization are dealt in their research group. He particularly shared example on importance of communication between athletes, coach, and scientist. Prof. Mattsson presented the attitudes and organizations needed to support innovations and new thinking. He showed practical examples of how diversity, thinking outside the box and cultural interest beside logic analysis can end up with new innovations in healthcare. As examples he showed how mathematics, the oil industry, knitting, and positive attitude towards “failures” had led to new medical products.

Overall, the seminar received a tremendous response from the Indian participants. In the coming months, we foresee collaboration with the Indian government, Indian hospitals with new health care innovations, Indian Sports Authorities, educational institutions, and private sports academies.  We as a team hope, this initiative will increase visibility of NTNU as an Innovative University, thereby, align with the NTNU’s vision of knowledge for the better world.

By Marlene Iversen Halvorsrød, PhD Candidate at CIUS

Treatment of ischemic heart disease has improved considerably the last decades. Not only the treatment itself, but also timing of treatment has been of great importance for this success. Nevertheless, ischemic heart disease is still the leading cause of death in the world.

The heart muscle, as every other muscle in the body, needs oxygen to maintain proper function. The coronary arteries supply the heart muscle with oxygenated blood. Ischemic heart disease is caused by stenosis or totally occlusion of this arteries and thereby reduced amount of available oxygen. This lack of oxygen can lead to permanent heart muscle damage. The longer the muscle have no available oxygen, the worse the damage will be. Treatment of ischemic heart disease is based on opening stenotic or occluded arteries to improve the accessibility of oxygen. Either by invasive blocking or medical (fibrinolytic) treatment. Time from debut of symptoms to treatment is a crucial determinant for success. The shorter ischemic time, the less heart muscle damage. After 6 hours without oxygen, the majority of heart muscle cells are likely to suffer from irreversible damage.

Classical symptoms of ischemic heart disease as heart attack are chest pain with radiation to neck and shoulder, shortness of breath and sweating. The symptoms are often related to physical activity. But this stenotic or occluded artery manifest with a great variability of symptoms that makes the diagnostic process hard and sometimes time consuming.

In addition to a patient’s symptoms, the most important quick diagnostic tool is the electrocardiogram (ECG). ECG was first used in late 1800 and is still a cornerstone in diagnosing ischemic heart diseases. ECG records the electrical signals through the heart. We classify heart attacks by the look of the ECG. A patient with chest pain and a certain pattern in ECG called ST-elevation, usually has an occluded artery and will be treated immediately. In some cases, patients lack this typical pattern in ECG, but have the same occluded artery. This group of patients does not have the same algorithm for immediate treatment and the treatment can be delayed. The consequence is more damaged heart muscles than necessary.

A lot of effort is put down to solve this diagnostic puzzle. In our research group at CIUS (Centre of Innovative Ultrasound Solutions), NTNU (Norwegian University of Science and Technology) we try to take advantage of new advanced ultrasound technology to come closer to a solution. Ultrasound is routinely used in diagnosing ischemic heart disease today by looking at regional differences in how the heart muscle contract. To see this regional impairment, you need a trained eye and good image quality. This method is also highly subjective. We want to improve this diagnostic step by using new technology developed at NTNU with high frame rate imaging that gives better time resolution, tissue doppler that can measure the speed of the heart muscle in different regions, and 3D ultrasound.

We know that it is crucial that patients with blocked coronary artery get treatment immediately. We want to improve the way we select these patients. Medical technical solutions can take time to develop, but in time we hope to brake some barriers in this important issue concerning the world’s deadliest disease.

In her work researcher Atrid Skjesol is revealing more details on how bacteria are causing inflammation.

By Astrid Skjesol, researcher at Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine.

The findings of a new target protein make it possible to find new treatment strategies to prevent serious inflammatory reactions toward Escherichia coli (E. coli) bacteria and sepsis.

In our recent research paper, published in PLOS Pathogens March 18, 2019 (https://doi.org/10.1371/journal.ppat.1007684) we have used extensive methods to reveal new details on how bacteria are causing inflammation.

Bacteria like E. coli are all around us. You can find E. coli everywhere in your environment, including on your skin and in your intestines. Most E. coli are harmless but some can make you very sick with uncontrolled inflammation that can cause a life threatening condition called sepsis. Sepsis can result from an infection anywhere in the body and is the most common cause of mortality in hospitals. It kills and disables millions and requires early suspicion and treatment for survival.

Despite current treatment strategies and advances in supportive care of critically ill patients, the mortality rate has barely decreased during the past decades. Therefore, there is a need for identifying new treatment strategies for preventing serious inflammatory reactions toward E. coli bacteria and for treating sepsis patients.  Based on our research a new target protein is identified, which is involved in cellular uptake and inflammatory reactions towards E. coli bacteria.  In our recent research we have used extensive methods to reveal new details on how bacteria are causing inflammation.

A central aim for our research is to develop technology to dampen unnecessary inflammation during blood stream E. coli infections to prevent septic shock. We do so by investigating how specialized immune cells like macrophages recognize and “eat” bacteria.

A cellular receptor on macrophages recognizes a specific pattern on the surface of E. coli. This receptor, called TLR4, works to turn on alarm signals, which are secreted to surrounding cells to help clear the ongoing infection.

From good to bad

TLR4 can also help cells to engulf bacteria and produce an alarm molecule (IFN-β). Normally, this alarm molecule can dampen inflammatory signaling, but overproduction of it  may mediate unwanted toxicity and induce pathological damage. So how to prevent an overproduction? (

The signaling pathway leading to secretion of the alarm molecule is dependent on the TLR4 adaptor molecule TRAM. We have discovered a novel binding-partner for TRAM, a protein called FIP2.
Removal of FIP2 or TRAM from human immune cells disables the cells from eating bacteria and producing too much alarm molecules (IFN-β)

Normally, the interaction between these two proteins contributes to activation and stabilization of other proteins which in turn are key players in the locomotion of the cells cytoskeleton during the process of bacteria engulfment. If the interaction between these proteins do not take place, the cells are less likely to overproduce alarm molecules.

Based on this research we aim to find new treatment strategies for preventing serious inflammatory reactions toward E. coli bacteria.

The results are published in “PLOS Pathogens” March 18, 2019 (https://doi.org/10.1371/journal.ppat.1007684)

Ill.1: Model describing molecules involved in bacterial uptake (phagocytosis) in an immune cell. (Illustration: Bjørnar Sporsheim)

Ill 2: Human immune cell (macrophage) engulfing E. coli (red). Newly formed filaments of the cytoskeleton (F-actin) is stained cyan. TRAM and FIP2 (green) are localized around the E. coli in patches overlapping with actin filaments. (Photo: Astrid Skjesol and Harald Husebye)

Ill 3: Super resolution microscopy of TRAM (green) when E. coli (red) enters a human macrophage. Newly forms filaments of the cytoskeleton (F-actin)  is stained cyan. (Photo: Astrid Skjesol and Harald Husebye)

Ill 3:

Foto: Karl Jørgen Marthinsen/NTNU

By Morten Wigen, postdoc researcher at the Institute for Circulation and Medical Imaging

Sweaty palms, dry mouth, itching collar from a tight tie, started struggling to keep focus after two hours of academic grilling. Barbeque season started early this year, I thought, feeling the heat from my opponents. Then the stress revealing words came: “I guess that was my last remark.” from the last challenger. 4.5 years summarized, questioned and discussed over three hours, and I was finally finished.

The idea of pursuing a PhD degree started to evolve during my master thesis project. This was my first experience of applying some of the accumulated knowledge from the years at the university, into a real project. There I developed a real-time computer program to synchronize ultrasound data with other physiological measurements (e.g. blood pressure, respiration pressure). The software was developed for research in the clinic at St. Olavs Hospital by anesthesiologists. I found the intersection between technology and medicine very interesting and motivating, and made me eager to continue within the field.

My supervisor, Lasse Løvstakken, had been working on novel ultrasound methods for blood flow imaging the last years. At the end of my Diploma, he received a grant from the Norwegian research council (NFR) for a PhD and a Postdoc position to develop this technology further. The method he wanted to focus on was Vector Flow Imaging (VFI), which is an ultrasound imaging mode to measure and visualize complex blood flow patterns in e.g. the hearts ventricles. The hypothesis was that this technique could be used for deeper understanding and diagnosis of abnormal heart function. The research from the NFR-grant span out into three main paths: 2D VFI in pediatrics (children), 2D VFI in fetus imaging and 3D VFI on adults. The PhD project was targeted on the latter, which I was fortunate to get, with Lasse as my continued supervisor.

In addition to the interdisciplinary perspective, I found the project very motivating due to its novelty, as no one had been working on the same topic before (3D VFI in the heart) and the use of a state-of-the-art ultrasound imaging system with all its technological capabilities.

Even though the end-goal of this work was clinical utility, the path towards it involved technological research. In my PhD this could be divided into three main parts:

1. Algorithmic design and implementation for processing of VFI data involving programming in C++, CUDA, Matlab and Python.
2. Investigation of ultrasound data acquisition techniques and setting this up on an ultrasound scanner.
3. Validation of the method using: variations of ultrasound simulations, different self-made ultrasound phantoms using 3D printing, phase-contrast MRI (the current golden standard for complex blood flow imaging).

As seen above, taking a PhD gave me the opportunity to work within many different areas, and pushed me into new unknown paths along the way. This has also caused some detours, but I have learned that also those eventually have resulted in useful knowledge.

Another unique part of taking a PhD was its opportunity to attend and present my research at conferences. On these travels, I have meet many other researchers working on related topics from all around the world, and have also formed tight bonds within the group. These interactions with fellow researchers within and outside the lab have been essential to grow and mature in the field.

Related to presenting my work, the first paragraph in this post was slightly exaggerated. I actually enjoyed my defense, despite it being a long tiring day. The reason for that has been solely the drilling in holding presentations the last years. When I started my PhD, defending the thesis one day was a fearsome thought, but has transformed into something I am much more comfortable with.

Today I am working as a Postdoc on related topics in the same group at NTNU, but have moved back to my hometown Oslo. Thanks to CIUS, however, I am lucky to work from an office at our collaborating ultrasound groups department at the university here (UiO).

Characteristics of doctors working in nursing homes and similar institutions in Norway in 2011, 2014 and 2017.

(Illustration: Colorbox)

This article describes some findings from the report Kartlegging av medisinskfaglig tilbud i sykehjem og heldøgns omsorgsboliger (Survey of professional medical services in nursing homes and residential care homes). Specifically, it presents descriptive characteristics of doctors employed in nursing homes or similar institutions in Norway in 2011, 2014 and 2017. Data are from KS’ (The Norwegian Association of Local and Regional Authorities) PAI register.

A total of 151 different municipalities were represented in the analyses: 103 municipalities in 2011, 108 in 2014 and 124 in 2017; and there were a total of 799 doctors working in nursing homes across these years. Specifically, there were 321, 383 and 448 doctors working in nursing homes in 2011, 2014 and 2017 respectively.

Turnover: As shown in Table 1, over two-thirds of the doctors worked in nursing homes in only one of the three years (2011, 2014 and 2017); and only approx. 10% of doctors worked in nursing homes at all three periods. These figures suggest high turnover. Even so, there was some improvement whereby, while approx. 7% of all doctors were only employed in 2011 and 2014, the proportion only employed in 2014 and 2017 rose to 15.1%.

Table 1: Continuity: Proportion of doctors employed in nursing homes in the period 2011-2017

Age: The doctors were between 25 and 80 years old during the study period, with an average age of 47 years in 2011, which then declined to 45 years in 2017.

Gender: The distribution of male and female doctors was fairly similar across the years. There was, however, a clear tendency towards more female doctors in nursing homes (from 42% in 2011 to 54% in 2017).

Figure 1: Gender distribution among the doctors. Source: PAI register data.

Part-time positions: Only 11% of doctors had a full-time position in 2011, and although this figure rose to 14% in 2014 and 24% in 2017, part-time employment is still the norm. Figure 2 also shows that women worked more hours (full time equivalents/FTEs) in nursing homes in 2011, 2014 and 2017 compared to men.

Table 2: Workload (% full-time equivalent) among the doctors.

Figure 2: Workload (% full-time equivalent/FTE) and gender among the doctors. Source: PAI register data. Workload (% full-time equivalent/FTE) is «the percent FTE on which the employee’s base salary is calculated” (1.00 = 100% = 37.5 hours per week).

The statistics here should be viewed with caution. Even though there are routines for assuring the quality of PAI register data, errors and omissions in the data can occur due to differences between municipalities in data reporting, and in how the variables in the register are defined and understood. Any such errors can lead to inaccuracies in the statistics reported here, which should therefore be approached with caution.

Reference:

Research report: Kartlegging av medisinskfaglig tilbud i sykehjem og heldøgns omsorgsboliger.
Authors: Melby, Line; Ågotnes, Gudmund; Ambugo, Eliva Atieno; Førland, Oddvar.

Decompression sickness: to consume with moderation.

Decompression Sickness (DCS) is a very serious hazard for divers, and for pretty much any profession subjected to rapid variations of environmental pressure. An individual in DCS may display a wide set of symptoms, ranging from skin rash and musculoskeletal pain to limb paralysis, coma and death.

A diver ascending from a dive too quickly can be viewed as a bottle of champagne being opened: a pressure differential appears between the gas phase dissolved within the diver’s tissues (the champagne inside the bottle) and the environment’s gas phase (the air now in contact with the champagne). As a result, the gas dissolved will expand and form bubbles until a state of equilibrium is achieved. However, an important difference is to be made between the diver and the bottle of champagne: bubbles are required for good champagne, but not so much for a healthy diver…

Various physiological mechanisms have been highlighted during DCS onset, which makes DCS a difficult pathology to investigate. A lot has already been done regarding the study of these physiological mechanisms, and we know now plenty about Reactive Oxygen Species production during diving, vascular dysfunction, thrombosis and so on. But still, we do not really understand DCS. Why?

Human physiology: when parts make up wholes.

Before diving into human physiology, let’s take a peek under the hood and have a look at how an engine works:

Each component seen above is essential for the engine to function properly. Each of these components, or parts, has specific properties such as size, weight, composition, form, but also the ability to rotate, slide, or even stay in place. The interesting thing is that none of them is able to transform fuel into movement. The engine does. The specific association of all these parts to make the engine, the whole, allows for additional properties that did not exist in the first place, that could be called “emergent properties. If one of the parts should fail, these emergent properties could disappear.

The human body functions in a same manner: with parts making up wholes, these wholes being parts of even bigger wholes. That is what is called integrative physiology. Understanding the structure and function of all the parts is not enough to comprehend the bigger picture. We need to understand the interplay between all the parts to understand the emergent properties of the whole.

Back to the study of DCS: even though we know how specific physiological mechanisms can be involved in DCS onset, we still do not understand the interplay between them. We lack integrative data. We lack knowledge about the relation between the parts and the emergent properties that fails during diving. We lack tools to look at the bigger picture.

Proteomics: looking at the parts to understand the whole.

In our parts-whole analogy, proteins could be considered as one of the smallest entities in body to have emergent properties. Being the end product of gene expression, they give us an accurate picture of what is going on in the body at a given time. Consequently, study them in a context of diving would allow for a deeper level of understanding of the ongoing processes during DCS onset.

Proteomics is a technique that gives us a way to look at such a deep level without any a priori bias. Proteomics does not look at a few proteins at a time; it gives us the ability to look at ALL the proteins simultaneously. Such insights as such a deep level of integration is fundamental to understand the interplay between all the various physiological mechanisms modified or failing during DCS.

Representative 2DE Gels (pH 4-7, SDS-PAGE 12%) for Rattus norvegicus plasma proteins form DCS group (A) and asymptomatic group (B). (Figure from Lautridou et al., Proteomics Clinical Applications, 2016).

The NTNU barophysiology group is working with proteomics in collaboration with several other teams in Europe since 2015. An ongoing collaboration with Malta aims at finding a specific biomarker of DCS early development that could help discriminate between healthy divers and divers in DCS. This study could also help us better understand the physiological modifications involved during the onset of this pathology by highlighting a set of proteins involved in similar responses; inflammatory processes for example.

Links to the previous proteomics studies:

Rat study: Effect of simulated air dive and decompression sickness on the plasma proteome of rats.

Human study: Evolution of the plasma proteome of divers before and after a single SCUBA dive.

Europe is facing urgent and significant challenges in maintaining sufficient standards of quality in healthcare. We discussed the increasing shortage of healthcare staff throughout Europe, as well as the high turnover of healthcare staff leaving the sector to continue their careers in different types of jobs and the growing percentage of occupational health-related disorders reported among healthcare staff (e.g. burnout, depression etc.) during an EAOHP “Healthy Healtcare” Small Group Meeting in March. Moreover, due to an aging workforce, more and more healthcare staff are expected to go to retirement. All of this has led to more and more healthcare employers searching for creative solutions to maintain and retain enough staff at work.

Healthy healthcare implies that healthcare systems are designed, managed and financed in balance with the available resources to improve workers’ health and performance as well as providing high quality of care (Illustration: iStock)

In our small group meeting, 26 participants came together to examine new, creative and more preventive solutions that can be found within the network of the European Academy of Occupational Health Psychology, and more specifically reflect, discuss and define the concept of a more Healthy Healthcare.

Healthy healthcare implies that healthcare systems are designed, managed and financed in balance with the available resources to improve workers’ health and performance as well as providing high quality of care. It emphasizes the importance of three distinct, but related, pillars that represent: (i) the healthcare system and working environment; (ii) staff wellbeing; and (iii) patient care. Ultimately, a balanced-based perspective taking into account the patient, staff and the complex healthcare system will lead to a more resource-efficient delivery of high quality healthcare services.

Ultimately, a balanced-based perspective taking into account the patient, staff and the complex healthcare system will lead to a more resource-efficient delivery of high quality healthcare services.

During the small group meeting, researchers shared evidence-based practice and research on one or more links between healthcare services and the work environment, staff wellbeing and the quality of patient care. Moreover, we discussed how to conduct interventions and research on healthy healthcare with different populations and settings. We ended the meeting summarizing important lessons-learned from the different presentations and discussions during the meeting and formulated a new research agenda for the future. More specifically the following take-home messages were formulated around the two points below:

What we know:

1. Most presentations include results of two out of the three pillars from the aforementioned Healthy Healthcare concept (patient, staff, and/or organizational practice). The most common pillar was the third one, which could include indicators of patient safety, satisfaction or other relevant patient-based outcomes.
2. Most results focused on negative predictors from the work environment or occupational health or well-being of healthcare staff (e.g. stressors at work, burnout etc.). Few studies address more positive outcomes like work engagement or meaning of work, and the simultaneously interplay between positive and negative factors and outcomes. Moreover, most studies focus on individual-level data, and do not report results on team-based or organisational level outcomes. Finally, unpaid work is a significant contributor to Quality of Care worldwide. The emotional demands of healthcare work equally affects professionals as voluntary workers in health care.
3. There was a heavy emphasis on the importance of a contingent perspective where one size does not fit all contexts and professions in healthcare. This means that a stressful demand in one context can be experienced as a job resource in another context.
4. In intervention design and implementation, the most effective programs are based on bottom-up (and team-based) methods where stakeholders help design the interventions. To sustain the effective bottom-up approaches, top-down management support is needed. Furthermore, process intervention research highlights the importance of a continuous learning cycle to create more healthy work environments that include learning goals for multiple stakeholders at different levels of healthcare institutions.
5. The importance of leadership in creating healthy workplaces was highlighted during the small group meeting, and has already received research attention in occupational health research. Nonetheless, a concept like health-promoting leadership has not yet been well established in occupational health research and models, and therefore warrants further exploration.
6. More and more technology is used in occupational health research to measure relevant predictors and outcomes as well as to implement intervention programs that facilitate Healthy Healthcare. However, the impact of this technology use on end-users has not yet been examined in detail. For example, one of the studies presented at this meeting highlighted the high drop-out of technology use across time. Few participants adhere to the whole intervention program cycle based on technology use and solutions may require a combination of online and offline (human based) intervention elements.
7. There is a need to develop a learning community to facilitate knowledge-sharing and best practice. Researchers are often connected to different employer associations with a network of >100 healthcare institutions that have relevant evidence-based practices to share. Moreover, large-scale datasets are available on a regional as well as a national level on healthcare data that are currently not yet used for further analyses by OHP researchers in Europe. Nonetheless, more data and practices exchange across Europe can help in synthesizing important findings and conclusions in relation to facilitating Healthy Healthcare.

What are the gaps in current research to develop more Healthy Healthcare projects?

1. One of the most important conclusions of our small group meeting is that all researchers recognize the importance of sharing the Healthy Healthcare concept in Europe. However, it will help to formulate a conceptual model to further facilitate integrated research in Europe on Healthy Healthcare.
2. The urgent need to retain enough healthcare staff was mentioned several times. Surprisingly, there is little exit research on the reasons as to why staff leave the healthcare sector and where they go?. We therefore call for more new research into this, and how these relate to indicators of occupational health-related topics (e.g. work stress, team climate, leadership, occupational health). Furthermore, we would like to raise more awareness and research on the impact of unpaid work in healthcare in relation to paid staff, patient outcomes and organisational practices in healthcare.
3. The added value of our joint occupational health network is currently unknown among EU-grant awarding institutions. The European Academy of Occupational Health Psychology could help with highlighting the joint impact of healthy healthcare research teams.
4. Occupational health researchers typically focus on the relationship between occupational health and organisational practices, but we also need to integrate results based on patient outcomes (e.g. patient outcomes, satisfaction or safety).
5. Based on our discussions we noticed substantial differences in (cross-cultural) context and therefore stress the importance of developing more cross-national case-comparative studies to further understand the role of cross-cultural differences. This was evident in the presentation by Dr. Safiye Sahin showing the extent of staff shortages in Turkey as well how the interpretation of work stress in Turkey differs in comparison to for example Norway.
6. More theoretical attention can be given to the gendered nature of healthcare work (e.g. gender roles) and to integrate life course perspectives on successful aging of staff members in healthcare work.
7. We need to write a joint position paper based on the aforementioned findings and present a clear research agenda. This will be done at the next EAOHP conference in Cyprus and in a special issue of Frontiers of Psychology: https://www.frontiersin.org/research-topics/9811/healthy-healthcare-empirical-occupational-health-research-and-evidence-based-practice.
8. The importance of creating a learning community moving forward. We hope that the EAOHP Executive recognizes this new consortium of researchers and the importance of providing more knowledge across contexts on Healthy Healthcare, and to support future meetings across Europe in the coming years on topics like:
   1. Positive interventions: process and implementation research;
   2. Develop theory model of Healthy Healthcare;
   3. Exchange knowledge on multi-level approaches and business cases;
   4. Exchange results on different research methodology: like realist evaluation (such as the Context-Mechanism-Outcome framework), process evaluation and learning from implementation sciences;
   5. Looking for national and European funding to start case-comparative studies on Healthy Healthcare across Europe;
   6. How to further communicate the idea of Healthy Healthcare to patients, managers, policymakers, practitioners and other stakeholders in this community;
   7. Health-promoting leadership/management in context.

The following months the consortium will investigate possible funds for further collaboration (on EU-level and national level). For more information or to join the Healthy Healthcare consortium please email Annet de Lange (annet.delange@han.nl).