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Objective Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns. Methods We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. Results Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion. Conclusions Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician. Practice implications Health professionals should be attentive to underlying existential messages embedded in the patient’s questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient’s needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health.

Accepted manuscript version. Published version available at https://doi.org/10.1016/j.jrurstud.2018.03.005. Accepted manuscript version, licensed CC BY-NC-ND 4.0. Many rural communities experience new growth through in-migration. In Herøy, Northern Norway, this is a result of increased labour migration in the fishing industry and a comprehensive effort by the municipality to encourage migrant workers to settle there. This paper addresses the ambiguities of creating stability through mobility. Through a case study from Herøy, we explore the complex relations between migrants' mobile economic practices and social integration processes by analysing how migrants engage with Herøy's landscape in multiple manners. This landscape entails networks of people and relations, materialities, dreams and hopes. Studying engagement, in addition to contestations and intersecting trajectories, we analyse how the landscape of those on the move is interrelated with that of those “being moved through”. We argue that creating stability in rural communities by encouraging migrant settlement requires going beyond economic integration – emphasising the more versatile and vulnerable processes of relating to unfamiliar places and worlds. It also requires an understanding of stability that embraces uncertainty and opens up towards various forms of belonging.

Cancer is a major health issue worldwide, and the global burden of cancer is expected to increase in the coming years. Whereas the limited success with current therapies has driven huge investments into drug development, the average number of FDA approvals per year has declined since the 1990s. This unmet need for more effective anti-cancer drugs has sparked a growing interest for drug repurposing, i.e. using drugs already approved for other indications to treat cancer. As such, data both from pre-clinical experiments, clinical trials and observational studies have demonstrated anti-tumor efficacy for compounds within a wide range of drug classes other than cancer. Whereas some of them induce cancer cell death or suppress various aspects of cancer cell behavior in established tumors, others may prevent cancer development. Here, we provide an overview of promising candidates for drug repurposing in cancer, as well as studies describing the biological mechanisms underlying their anti-neoplastic effects.

Purpose The main aim was to map serum levels of IL-1/IL-6 family cytokines and relevant receptors from serum samples taken across treatment in patients with Renal Cell Carcinoma (RCC). Additionally, we explored the possible interactions between these measurements, immunohistochemistry and intratumoral blood flow. Methods We included 40 patients undergoing open surgery for renal tumors. Blood samples were collected before, during (taken simultaneously from a peripheral site and the renal vein (RV) before clamping) and after surgery. Samples were analyzed for IL-6, IL-27, IL-31, OSM, TNF-α, serum (s)-gp130, s-IL-6Rα, s-IL-33R, IL-1Rα and VEGF. All 35 RCC tumors were histologically subtyped as clear cell (CCRCC), papillary or chromophobe. Immunohistochemistry for the CCRCC group included expression of IL-6/IL-6R. Intratumoral blood flow was determined by calculating intratumoral contrast enhancement on preoperative computerized tomography (CT) imaging. Results In the CCRCC patients, the intraoperative RV concentration of IL-6 was significantly higher than in both the preoperative and postoperative samples (p = 0.005 and p = 0.032, respectively). Furthermore, the intraoperative ratio showed significantly higher levels of IL-6 in the RV than in the simultaneously drawn peripheral sample. Immunohistochemistry showed general expression of IL-6 (23/24) in both tumor cells and the vasculature (20/23). Moreover, s-IL-6R was expressed in tumor cells in 23/24 studied patients. Increased blood flow in the CCRCC tumors predicted increased IL-6 levels in the RV (p < 0.001). The other cytokines and receptors showed an overall stability across the measurements. However, the intraoperative ratios of IL-33R and gp130 showed significantly higher levels in the RV. Conclusion Serum levels of IL-6 increased during surgery. Intraoperative IL-6 and s-IL-33R values were higher in the RV compared to the periphery, suggesting secretion from the tumor or tumor microenvironment itself. Supportive of this is an almost general expression of IL-6/s-IL-6R in tumor cells and IL-6 in vasculature in the tumor microenvironment. Other studied cytokines/receptors were remarkably stable across all measurements. publishedVersion

Aim According to Norwegian law, an autonomous patient has the right to refuse life-prolonging treatment. If the patient is not defined as dying, however, health personnel are obliged to instigate life-saving treatment in an emergency situation even against the patient's wishes. The purpose of this study was to investigate how doctors' attitudes and knowledge agree with these legal provisions, and how the statutory provision on emergency situations influences the principle of patient autonomy for severely ill, but not dying, patients. Method A strategic sample of 1175 Norwegian doctors who are specialists in internal medicine, paediatrics, surgery, neurology and neurosurgery received a mail questionnaire about decisions on end-of-life care in hypothetical scenarios. The case presented concerns a 45-year-old autonomous patient diagnosed with end-stage ALS who declines ventilatory treatment. Recipients were randomly selected from the membership roster of the Norwegian Medical Association. 640 (54.5%) responded; of these, 406 had experience with end-of-life decisions. Results 56.1% (221/394) stated that ALS patients in such situations can always refuse life-prolonging treatment, and 42.4% (167/394) were of the opinion that the patient can normally refuse life-prolonging treatment. 1.5% (6/394) stated that the patient can not refuse life-prolonging treatment. Conclusions The answers indicate that the respondents include patients' refusal in an overall clinical judgement, and interpret patients' right to decline life-saving treatment in different ways. This may reflect the complex legal situation in Norway regarding patient autonomy with respect to the right of severely ill, but not dying, patients' right to decline acute life-saving treatment.

To study attitudes regarding life-saving interventions.An Internet questionnaire describing 6 patients of different ages needing resuscitation was sent to members of the Norwegian Pediatric Association (n = 676): a 24-week gestational age infant, a term infant, a 2-month-old infant, a 7-year, a 50-year, and an 80-year-old individual. Neonates had similar or better described outcomes than older patients.A total of 266 people responded (39.4%). The majority would resuscitate all the patients except the 80-year-old. The majority thought that resuscitation was in the best interest of the younger 5 patients, but fewer thought so for neonates (P.05). Although the majority of the respondents thought that resuscitation was in the neonates' best interest (71% for 24-week-old and 75% for term infant), significantly more would accept comfort care at parental demand (62% for 24-week-old and 72% for term infant), unlike for other scenarios. Quality of life was used to justify decision making; 25% used the length of the life for neonates to motivate their answers. Patients were prioritized for resuscitation in the following order: 2-month-old infant, 7-year-old child with multiple disabilities, 50-year-old adult, the neonates, and lastly the 80-year-old individual.There are challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations. Neonates seem to be devalued.

It was shown in the present study that it is possible to produce TiO 2 scaffolds with both high mechanical strength and high porosity by using the polymer sponge method. TiO 2 scaffolds with porosity above 85% exceeded 1 MPa in compressive strength. TiO 2 scaffolds with equally high compressive strength having a fully open porosity close to 90% is not previously been reported in the literature. Reduction of porosity leads to even further reinforce the scaffolds’ mechanical structure. A statistical correlation study with 160 tested scaffolds defined the most important manufacturing steps and the governing morphological characteristics for the scaffold's increased mechanical strength. The key manufacturing factors were a holding phase during sintering time for more than 30 h (at 1500 °C) and multiple coatings of the scaffold's structure. The crucial parameters for high mechanical strength were the fractal dimensions of the struts, object surface/volume ratio, density and overall porosity.

A metal hydride (MH) storage unit and a polymer electrolyte membrane (PEM) fuel cell (FC) stack were thermally integrated through a common water circulation loop. The low temperature waste heat dissipated from the fuel cell stack was used to enhance and ensure the release of hydrogen from the storage unit. A water-heated MH-tank can be made more compact than an air-heated MH-tank with external heating fins, due to more direct heat transfer between MH-alloy and heating/cooling media. A water-heated MH-tank will therefore have the potential for better kinetics for absorption and desorption of hydrogen. The fuel cell stack and metal hydride storage unit were characterised and a control strategy was developed for fast start-up of the fuel cell stack. The main priority for the strategy was to maintain the metal hydride temperature at room temperature, while increasing the FC temperature to the specified operating temperature. The preferred strategy for this system was to increase the fuel cell temperature to at least 40 °C before starting to heat the metal hydride storage unit to 30 C. Without thermal integration, it was not possible to utilize the full hydrogen storage capacity of the metal hydride storage unit due to cooling of the tank.

A numerical model for the transient hydrogen charge/discharge rates and thermal behaviour of metal hydride stores was developed and verified against experiments using a cylindrical reactor filled with AB5-type metal hydride. The model assumes local thermal equilibrium between the gas and solid phases, and incorporates the pressure and temperature-dependent hydrogen reaction rates, as well as heat transfer in the porous metal hydride bed. The model was verified through experimental data. The experiments were performed using a unit with hydrogen storage capacity of 130 Nl H2; the store was submerged in an isothermal water bath. Experiments at different water bath temperatures and charge/discharge hydrogen pressures indicated a relation between charge/discharge time and these parameters. The reactor’s ability to deliver a constant hydrogen flow at different water bath temperatures was experimentally investigated. During simulations it was found that the model applied is sensitive to perturbations of some of its parameters; activation energy of absorption, effective conductivity and heat of reaction were found to be the most important ones. The charge and discharge performances of the store are controlled by the reaction rate in the first half-part of the H absorption/desorption experiments and by a heat transfer in the second half-part of charge/discharge. a 2009 Published by Elsevier Ltd on behalf of International Association for Hydrogen Energy.

para -Substituted α-fluoroacetophenones have been synthesised by three different routes. Electrophilic fluorination of trimethylsilyl enol ethers of acetophenones using Selectfluor (F–TEDA–BF 4 , 1-chloromethyl-4-fluoro-1,4-diazoniabicyclo[2.2.2]octane bis-(tetrafluoroborate)) gave high to moderate yield depending on the electronic properties of the substituents. F–TEDA–BF 4 mediated fluorination of acetophenones in methanol resulted in a mixture of α-fluoroacetophenones and the corresponding 2-fluoro-1,1-dimethyl acetals. The dimethyl acetals were hydrolysed using trifluoroacetic acid in water to maximise the yield of the product. Nucleophilic fluorination of α-bromoacetophenones using tetrabutylammonium hydrogen bifluoride (TBABF) led to moderate yield when having electron-donating substituents, whereas low yields were experienced when more electron-withdrawing substituents were introduced.

Metal hydrides can store hydrogen at low pressures and with high volumetric capacity. For the possible application as storage medium in hydrogen stand-alone power systems, large metal hydride hydrogen storage units are usually required. A reliable and verified kinetic correlation is an important tool in the designing process of a larger storage unit. This paper describes kinetic investigation of a AB5-type alloy and its corresponding hydride, with the purpose of finding a semi-empirical correlation suitable for use in heat and mass transfer modelling and engineering design of metal hydride storage units.

The purpose of the experiment was to evaluate effects of partial replacement of fish meal with soybean meal on digestibility in Atlantic cod and effects of biotechnological processing of soybean meal. Other objectives were to find out if apparent digestibility in cod was affected by age, temperature and/or faecal sampling methods, and to map digestion and absorption patterns along the intestinal tract for different age classes and diets. A control diet with fish meal as the main protein source (FM), a diet with 24% of crude protein from conventional extracted soybean meal (SBM), and a diet with 24% of crude protein from a bioprocessed soybean meal (BP-SBM) were used. Yttrium oxide was added as an inert marker for digestibility determination. The diets were fed to duplicate groups of 534 g (1-year-old) and 1750 g (2-year-old) cod in seawater. Faeces were stripped from the distal-most section (distal chamber) of the intestine after 48 and 84 days of feeding. In addition, intestinal contents were removed by dissection after 84 days. The dissected intestine was divided into 5 sections and contents were analysed separately. Dietary soy did not alter the viscosity of the digesta. The replacement of fish meal protein with soybean protein reduced the apparent digestibility of crude protein, fat, energy and almost all amino acids, independent of type of soybean meal processing. Larger fish had higher digestibility of starch, ash and several amino acids than smaller fish. A temperature decrease from 9.1 °C at feeding day 48 to 6.8 °C at day 84 resulted in lower digestibility of starch, ash and several amino acids. Absorption of amino acids was quantitatively terminated in the distal part of the mid intestine when feeding the soy-containing diets, but continued into the distal chamber when feeding the FM diet. Absorption of fat was completed in the proximal part of the mid intestine when feeding the soy-containing diets, but continued into the middle part of the mid intestine when feeding the FM diet. Soy did not affect absorption pattern of starch along the intestinal tract. Faecal sampling by dissection resulted in higher apparent digestibility of macronutrients than stripping in the 2-year-old cod, and higher apparent digestibility of protein in the 1-year olds.

This experiment evaluated the nutritional value of extracted soybean meal (SBM) for on-grown Atlantic cod, and if this was improved by bioprocessing into a product with reduced contents of antinutrients (BPSBM). Three iso-nitrogenous and iso-energetic extruded diets contained no soy (FM control), or 24% of total protein from either soy product. Each diet was fed to duplicate groups of 534 g (1-year old) and 1750 g (2-year old) cod in sea pens equipped with feed waste collectors. The experiment lasted 84 feeding days, the fish were weighed at days 48 and 84, and fish were sampled at days 0 and 87 to budget protein and energy utilisation by comparative slaughter. At day 48 faeces was collected for estimation of macronutrient, energy, and amino acid digestibility. The 1-year old cod reached weights ranging from 916 to 984 g, while the 2-year olds reached weights ranging from 2490 to 2644 g. There was no effect of age-class on growth rate estimated as TGC, but relative feed intake (% of BW) and FER were higher in the 1-year olds. Digestibility and retention of macronutrients were not affected by size. Still, the digestibility of most amino acids and the retention of several digested amino acids were highest in the 2-year olds. The body lipid content was similar in all groups, and did not change. There was no effect of diet on weight gain within age-classes, nor any general effect of diet on growth rate estimated as TGC. The digestibility of amino acids and the lipid was reduced when feeding the SBM and BPSBM diets, but cod of both age-classes compensated for this by increased feed intake and gastrointestinal growth, resulting in lower FER and reduced protein retention. Similar growth and body composition when feeding all diets and similar macronutrient and protein utilisation when feeding SBM and BPSBM showed that Atlantic cod have relatively high tolerance for dietary SBM.

The aim was to study the possibility to reduce the pH-drop post mortem in cod muscle by reducing glycolysis or increasing the buffer capacity, hence reducing liquid leakage and fillet gaping during storage. Two feeding experiments were performed with 1-year-old farmed cod (mean weight 0.6 kg–0.9 kg) fed extruded commercial dry feed coated with Experiment 1: sodium oxalate (5 g or 25 g kg − 1 ), quercetin (5 mg or 25 mg kg − 1 ), ascorbic acid (1 g or 5 g kg − 1 ) or magnesium aspartate (5 g or 25 g kg − 1 ), and Experiment 2: two levels of histidine (12 or 48 g kg − 1 ), sodium citrate (24 g kg − 1 ), or a combination of histidine and citrate (12 and 24 g kg − 1 , respectively). The cod were kept in duplicate net pens (125 m 3 ) per dietary treatment. In both experiments, samples were collected for analysis after 1 and 3 weeks of feeding. Dietary supplementation with sodium oxalate, quercetin or magnesium aspartate showed no effect on pH, liquid leakage or gaping, whereas the highest level of ascorbic acid gave an unexpected lower pH and higher liquid leakage during cold storage. These results show that the positive health effects commonly obtained by boosting using high levels of ascorbic acid may be counteracted by reduced fillet quality. The feed containing the highest level of histidine gave a significantly higher content of free histidine, higher muscle pH and lower gaping after 3 weeks of feeding. This indicates that dietary histidine accumulates in cod muscle and increases the buffer capacity post mortem. The liquid leakage from raw muscle was, however, not reduced. Surprisingly, the muscle content of anserine (β-alanyl-π-methyl- l -histidine) and other histidine related compounds (1-methyl-histidine, 3-methyl histidine and carnosine) was not affected by the increased dietary histidine. Dietary supplementation of citrate did not significantly alter post mortem muscle pH, gaping or liquid leakage.

The meaning of being in ethically difficult care situations in pediatrics as narrated by male registered nurses

Aim: Previous studies indicate that Norwegian physicians hold conservative attitudes towards ethically controversial end-of-life decisions. The present study was undertaken to explore whether in Norway euthanasia may be hidden under labels such as death after analgesic injections and withholding or withdrawing treatment. Methods: A postal questionnaire containing 76 questions on ethical, collegial and professional autonomy issues was sent to a representative sample of 1616 active physicians in Norway in 2000. Results: 83% responded. A total of 8.1% had terminated life-prolonging treatment based on the resource situation, while 53.5 and 40.1% respectively had stopped life prolonging treatment due to the wish of the patient and the wish of the patient's relatives. Although not significantly, anaesthesiologists more often reported to have stopped treatment due to resource considerations. One percent of the physicians reported to have shortened a patient's life intentionally (other than stopping futile treatment). All of these were men. Logistic regression showed no effect when gender, age and specialty were analysed simultaneously. 10.6%, and male more often than female physicians, had had experience of unintentional patient death in relation to pain treatment. Anaesthesiologists had had experiences of death following an analgesic injection no more than other specialists. Conclusions: Only a small minority of Norwegian physicians has committed euthanasia. However, patient death has occurred following ethically questionable decisions such as withdrawal of treatment based on resource considerations and requests from the family.

This study is a part of a comprehensive investigation into the narratives of male and female physicians and nurses concerning their experience of being in ethically difficult care situations in paediatrics. Seventeen male physicians with a range of levels of expertise, working on various wards in paediatric clinics at two university hospitals in Norway, narrated 78 stories. The transcribed interview texts were subjected to hermeneutic analysis. All the interviewees related problems in both an action and a relation ethics perspective. The main focus was on ethical problems concerning life and death decisions. The central theme was overtreatment, which they felt they could easily slip into because of a lack of exact knowledge about the outcome of life-saving treatment. The less experienced physicians required criteria and ethical guidelines that could tell them when to stop treatment, and they expected the more experienced physicians to be able to teach them about such things. The more experienced physicians, however, told a different story about life-saving practices in paediatrics. They spoke of a very demanding life situation. In such a situation communication seems decisive, not only to clarify treatment questions, but primarily to cope with life. The physicians' main concern seemed to be the parents rather than the children. Both groups underlined the importance of professional distance to patients and to ethical problems.

Sixteen statements on physician attitudes in the physician-patient relationship were presented to a representative sample of Norwegian physicians (N=990). Three moderately correlated theoretical dimensions were identified in a principal component analysis: paternalism, patient autonomy, and moral deliberation. The paternalism scores increased significantly with age, and psychiatrists scored significantly lower than physicians in somatic specialties. Psychiatrists had the highest scores on the patient autonomy dimension, whereas surgeons scored the lowest. Moral deliberation scores increased slightly with age. To explore the pattern of scores across the three dimensions, the scores were dichotomized and combined in eight different ways. The resulting typology included five different physician profiles: (1) classical paternalists (high scores on paternalism, low scores on both patient autonomy and moral deliberation), (2) modern paternalists (high scores on both paternalism and deliberation, low scores on patient autonomy), (3) autonomists ( high scores on patient autonomy, low scores on both paternalism and deliberation), (4) deliberationists (high scores on deliberation and patient autonomy, low scores on paternalism), and (5) ambivalents (high or low scores on all dimensions, or high or low scores on both paternalism and patient autonomy). The four groups of physicians with 'consistent' attitudes contained between 12 and 19% of the total sample, whereas 37% belonged to the 'ambivalent' group. Laboratory doctors and surgeons belonged significantly more often in the group of classical paternalists than did general practitioners, whereas male physicians were more often modern paternalists than were female physicians. Among the autonomists, women were more numerous than men, doctors in their 40s clearly more numerous than those in their 60s, and psychiatrists clearly more numerous than residents.

The ethical guidelines of the Norwegian Medical Association strongly condemn physician participation in euthanasia and assisted suicide. A previous study on attitudes towards euthanasia in the Norwegian population, however, indicates that a substantial part of the population is quite liberal. This study explores Norwegian physicians' attitudes towards and experience with end of life dilemmas. Sixty-six percent of a representative sample of 1476 who received postal questionnaires responded. They confirmed that Norwegian physicians actually seem to hold quite restrictive attitudes towards euthanasia. Seventeen percent answered yes to a question of whether a physician should have the opportunity to actively end the life of a terminal patient in great pain who requests this help, while 4% agreed that the same could be done to a chronically ill patient with great pain and a poor quality of life who otherwise would have several more years to live. Six percent of the physicians had performed actions intended to hasten a patient's death, while 76% said that they at least once had treated patients even if they had felt that treatment should have been discontinued. A multiple logistic regression analysis showed that internal medicine specialists, surgeons and psychiatrists were significantly more restrictive than their colleagues in laboratory specialties, and that physicians educated abroad and those with negative attitudes towards patient autonomy had more liberal attitudes towards euthanasia, when gender and time since graduation from medical school were controlled for.

Summary Background The evacuation of emergency cases by air, usually by helicopter, is controversial because of the cost of the programme, the possibility of an accident (especially in an urban area), and unproven benefit. But such evacuations cannot be studied by a random intervention (eg, air versus ground ambulance). We used an expert-panel approach to estimate the health outcome for patients transferred by emergency helicopter compared with the potential outcome if they had gone by surface ambulance. Methods The helicopter programme is based at the University Hospital of Troms o in northern Norway. 370 case-reports of helicopter evacuation from rural areas were screened by anaesthetists for routine and case-specific data. Two expert panels assessed the cases for potential additional health benefit arising from the fact of helicopter evacuation. The panels used a modified Delphi technique to reach consensus in life-years gained. One panel met for cases aged under 15 and pregnant women, the other for older cases. Findings 240 of the 370 cases were male (65%); the age range for both sexes was 0-86 years. The most common diagnosis for the 55 cases aged under 15 was infection (49%); in older patients, cardiovascular disease dominated (50%). Trauma accounted for just under a fifth of cases in both groups. On average, the patients arrived 69 min (range 0-615) earlier in hospital than if they had gone by ground transport. For 283 cases, the initial screening by the anaesthetists indicated no additional benefit compared with that obtainable by ground-ambulance transport. The main reason was that no treatment was given during the flight or early on in hospital that could not have been given otherwise. 90 cases entered the expert panel system. Of these 90, 49 cases were judged to have received no additional benefit. This left 41 (11% of the total of 370 evacuated) who were judged to have benefited, gaining 290·6 life-years. 96% of the total number of life-years gained was achieved in nine patients, six of whom were aged below 7 (four were aged 0-7 months). The life-year-gain per adult patient with cardiovascular disease was 0·54. Interpretation We conclude that an emergency helicopter service can provide considerable health benefits for selected patients, at least in this rural setting. Given the costs and risks of such a service, the benefits for most patients are small.

This study explores mechanisms involved in self-evaluation of health by making specifications of linkages among various dimensions of health status, physiological measures, social and behavioral factors or characteristics. The proposed structural equation model is tested by using data from a comprehensive health survey of the population of Finnmark county, Norway (1987-88), including 4549 men and 4360 women aged 30-62. The findings suggest the burden of physical distress and reliance on permanent disablement benefit to play the key role in reducing self-evaluated health. The seemingly strong labelling impact of permanent work disability, contrasted the modest effect of diagnoses of chronic disease. Moreover, the impact of both these key factors and other important determinants is strongly socially patterned. Positive health related life-style appeared to have a positive impact on self-rated health, while preoccupation with health had a negative impact. This finding adds some credibility to the suggestion that the growing occupation and fascination with health have some negative health outcomes.