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1.  Legal prerequisites for ecosystem-based management in the Baltic Sea area: The example of eutrophication 
Ambio  2015;44(Suppl 3):370-380.
The purpose of this paper is to discuss the role of law in the management of the Baltic Sea, with focus on eutrophication. It aims to identify legal instruments or structures realizing an ecosystem approach. This also includes a discussion of the prerequisites of law as contributor to ecosystem-based management (EBM), as well as evaluation of current legal instruments. While ecosystem approach to environmental management is central to contemporary environmental management policy, it is still unclear what such an approach entails in concrete legal terms. The scope of the analysis stretches from international and EU legal regimes, to implementation and regulation within the national legal systems. A conclusion is that the management structures need further development to properly realize EBM, for example, through concretization of management measures, and clarification of duties and responsibilities for their realization.
PMCID: PMC4447696  PMID: 26022320
Law; Baltic Sea; Ecosystem approach; Adaptive governance; Social–ecological resilience; Comparative law
2.  E-assessment and an e-training program among elderly care staff lacking formal competence: results of a mixed-methods intervention study 
Among staff working in elderly care, a considerable proportion lack formal competence for their work. Lack of formal competence, in turn, has been linked to higher staff ratings of stress symptoms, sleep disturbances and workload. Objectives: 1) To describe the strengths and weaknesses of an e-assessment and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of an e-training program on staff members’ working life (quality of care and psychological and structural empowerment) and well-being (job satisfaction and psychosomatic health). The hypothesis was that staff who had completed the e-assessment and the e-training program would rate greater improvements in working life and well-being than would staff who had only participated in the e-assessments.
An intervention study with a mixed-methods approach using quantitative (2010–2011) and qualitative data (2011) was conducted in Swedish elderly care. Participants included a total of 41 staff members. To describe the strengths and weaknesses of the e-assessment and the e-training program, qualitative data were gathered using semi-structured interviews together with a study-specific questionnaire. To study the effects of the intervention, quantitative data were collected using questionnaires on: job satisfaction, psychosomatic health, psychological empowerment, structural empowerment and quality of care in an intervention and a comparison group.
Staff who completed the e-assessments and the e-training program primarily experienced strengths associated with this approach. The results were also in line with our hypotheses: Staff who completed the e-assessment and the e-training program rated improvements in their working life and well-being.
Use of the e-assessments and e-training program employed in the present study could be one way to support elderly care staff who lack formal education by increasing their competence; increased competence, in turn, could improve their self-confidence, working life, and well-being.
PMCID: PMC4438631  PMID: 25943436
Competence in elderly care; E-assessment of prior learning; Information and communication technology; Informal education; Mixed-methods; Well-being; Working life
3.  E-assessment of prior learning: a pilot study of interactive assessment of staff with no formal education who are working in Swedish elderly care 
BMC Geriatrics  2014;14:52.
The current paper presents a pilot study of interactive assessment using information and communication technology (ICT) to evaluate the knowledge, skills and abilities of staff with no formal education who are working in Swedish elderly care.
Theoretical and practical assessment methods were developed and used with simulated patients and computer-based tests to identify strengths and areas for personal development among staff with no formal education.
Of the 157 staff with no formal education, 87 began the practical and/or theoretical assessments, and 63 completed both assessments. Several of the staff passed the practical assessments, except the morning hygiene assessment, where several failed. Other areas for staff development, i.e. where several failed (>50%), were the theoretical assessment of the learning objectives: Health, Oral care, Ergonomics, hygiene, esthetic, environmental, Rehabilitation, Assistive technology, Basic healthcare and Laws and organization. None of the staff passed all assessments. Number of years working in elderly care and staff age were not statistically significantly related to the total score of grades on the various learning objectives.
The interactive assessments were useful in assessing staff members’ practical and theoretical knowledge, skills, and abilities and in identifying areas in need of development. It is important that personnel who lack formal qualifications be clearly identified and given a chance to develop their competence through training, both theoretical and practical. The interactive e-assessment approach analyzed in the present pilot study could serve as a starting point.
PMCID: PMC3998952  PMID: 24742168
Non-formal education; Elderly care; E-assessment of prior learning; Caregivers
4.  Life values as predictors of pain, disability and sick leave among Swedish registered nurses: a longitudinal study 
BMC Nursing  2011;10:17.
Prospective studies on high-risk populations, such as subgroups of health care staff, are limited, especially prospective studies among staff not on sick-leave. This paper is a report of a longitudinal study conducted to describe and compare the importance and consistency of life domains among registered nurses (RNs) working in a Swedish hospital and evaluate a model based on the consistency of valued life domains for prediction of pain, disability and sick leave.
Importance and consistency ratings of life values, in 9 domains, were collected during 2003 and 2006 from 196 RNs using the Valued Living Questionnaire (VLQ). Logistic regression analyses were used for prediction of pain, disability and sick leave at the three-year follow-up. The predictors family relations, marriage couples/intimate relations, parenting, friends/social life, work, education, leisure time, psychological well-being, and physical self-care were used at baseline.
RNs rated life values regarding parenting as most important and with the highest consistency both at baseline and at follow-up. No significant differences were found between RNs' ratings of importance and consistency over the three-year period, except for friends/social relations that revealed a significant decrease in importance at follow-up. The explanatory models for pain, disability and sick leave significantly predicted pain and disability at follow-up. The odds of having pain were significantly increased by one consistency rating (psychological well-being), while the odds were significantly decreased by physical self-care. In the model predicting disability, consistency in psychological well-being and education significantly increased the odds of being disabled, while consistency in physical self-care significantly decreased the odds.
The results suggest that there might be a link between intra-individual factors reflecting different aspects of appraised life values and musculoskeletal pain (MSP).
PMCID: PMC3198938  PMID: 21958331
5.  Polymorphic Mutation Frequencies in Escherichia coli: Emergence of Weak Mutators in Clinical Isolates 
Journal of Bacteriology  2004;186(16):5538-5542.
Polymorphisms in the rifampin resistance mutation frequency (f) were studied in 696 Escherichia coli strains from Spain, Sweden, and Denmark. Of the 696 strains, 23% were weakly hypermutable (4 × 10−8 ≤ f < 4 × 10−7), and 0.7% were strongly hypermutable (f ≥ 4 × 10−7). Weak mutators were apparently more frequent in southern Europe and in blood isolates (38%) than in urinary tract isolates (25%) and feces of healthy volunteers (11%).
PMCID: PMC490890  PMID: 15292159
6.  Biological Costs and Mechanisms of Fosfomycin Resistance in Escherichia coli 
Fosfomycin is a cell wall inhibitor used mainly for the treatment of uncomplicated lower urinary tract infections. As shown here, resistance to fosfomycin develops rapidly in Escherichia coli under experimental conditions, but in spite of the relatively high mutation rate in vitro, resistance in clinical isolates is rare. To examine this apparent contradiction, we mathematically modeled the probability of resistance development in the bladder during treatment. The modeling showed that during a typical episode of urinary tract infection, the probability of resistance development was high (>10−2). However, if resistance was associated with a reduction in growth rate, the probability of resistance development rapidly decreased. To examine if fosfomycin resistance causes a reduced growth rate, we isolated in vitro and in vivo a set of resistant strains. We determined their resistance mechanisms and examined the effect of the different resistance mutations on bacterial growth in the absence and presence of fosfomycin. The types of mutations found in vitro and in vivo were partly different. Resistance in the mutants isolated in vitro was caused by ptsI, cyaA, glpT, uhpA/T, and unknown mutations, whereas no cyaA or ptsI mutants could be found in vivo. All mutations caused a decreased growth rate both in laboratory medium and in urine, irrespective of the absence or presence of fosfomycin. According to the mathematical model, the reduced growth rate of the resistant strains will prevent them from establishing in the bladder, which could explain why fosfomycin resistance remains rare in clinical isolates.
PMCID: PMC182645  PMID: 12936984
7.  Carbon Starvation Can Induce Energy Deprivation and Loss of Fermentative Capacity in Saccharomyces cerevisiae 
Seven different strains of Saccharomyces cerevisiae were tested for the ability to maintain their fermentative capacity during 24 h of carbon or nitrogen starvation. Starvation was imposed by transferring cells, exponentially growing in anaerobic batch cultures, to a defined growth medium lacking either a carbon or a nitrogen source. After 24 h of starvation, fermentative capacity was determined by addition of glucose and measurement of the resulting ethanol production rate. The results showed that 24 h of nitrogen starvation reduced the fermentative capacity by 70 to 95%, depending on the strain. Carbon starvation, on the other hand, provoked an almost complete loss of fermentative capacity in all of the strains tested. The absence of ethanol production following carbon starvation occurred even though the cells possessed a substantial glucose transport capacity. In fact, similar uptake capacities were recorded irrespective of whether the cells had been subjected to carbon or nitrogen starvation. Instead, the loss of fermentative capacity observed in carbon-starved cells was almost surely a result of energy deprivation. Carbon starvation drastically reduced the ATP content of the cells to values well below 0.1 μmol/g, while nitrogen-starved cells still contained approximately 6 μmol/g after 24 h of treatment. Addition of a small amount of glucose (0.1 g/liter at a cell density of 1.0 g/liter) at the initiation of starvation or use of stationary-phase instead of log-phase cells enabled the cells to preserve their fermentative capacity also during carbon starvation. The prerequisites for successful adaptation to starvation conditions are probably gradual nutrient depletion and access to energy during the adaptation period.
PMCID: PMC161471  PMID: 12788723
8.  Error-prone initiation factor 2 mutations reduce the fitness cost of antibiotic resistance 
Molecular Microbiology  2010;75(5):1299-1313.
Mutations in the fmt gene (encoding formyl methionine transferase) that eliminate formylation of initiator tRNA (Met-tRNAi) confer resistance to the novel antibiotic class of peptide deformylase inhibitors (PDFIs) while concomitantly reducing bacterial fitness. Here we show in Salmonella typhimurium that novel mutations in initiation factor 2 (IF2) located outside the initiator tRNA binding domain can partly restore fitness of fmt mutants without loss of antibiotic resistance. Analysis of initiation of protein synthesis in vitro showed that with non-formylated Met-tRNAi IF2 mutants initiated much faster than wild-type IF2, whereas with formylated fMet-tRNAi the initiation rates were similar. Moreover, the increase in initiation rates with Met-tRNAi conferred by IF2 mutations in vitro correlated well with the increase in growth rate conferred by the same mutations in vivo, suggesting that the mutations in IF2 compensate formylation deficiency by increasing the rate of in vivo initiation with Met-tRNAi. IF2 mutants had also a high propensity for erroneous initiation with elongator tRNAs in vitro, which could account for their reduced fitness in vivo in a formylation-proficient strain. More generally, our results suggest that bacterial protein synthesis is mRNA-limited and that compensatory mutations in IF2 could increase the persistence of PDFI-resistant bacteria in clinical settings.
PMCID: PMC2859245  PMID: 20132454
9.  The Study of Active Monitoring in Sweden (SAMS): A randomized study comparing two different follow-up schedules for active surveillance of low-risk prostate cancer 
Scandinavian Journal of Urology  2013;47(5):347-355.
Only a minority of patients with low-risk prostate cancer needs treatment, but the methods for optimal selection of patients for treatment are not established. This article describes the Study of Active Monitoring in Sweden (SAMS), which aims to improve those methods.
Material and methods
SAMS is a prospective, multicentre study of active surveillance for low-risk prostate cancer. It consists of a randomized part comparing standard rebiopsy and follow-up with an extensive initial rebiopsy coupled with less intensive follow-up and no further scheduled biopsies (SAMS-FU), as well as an observational part (SAMS-ObsQoL). Quality of life is assessed with questionnaires and compared with patients receiving primary curative treatment. SAMS-FU is planned to randomize 500 patients and SAMS-ObsQoL to include at least 500 patients during 5 years. The primary endpoint is conversion to active treatment. The secondary endpoints include symptoms, distant metastases and mortality. All patients will be followed for 10–15 years.
Inclusion started in October 2011. In March 2013, 148 patients were included at 13 Swedish urological centres.
It is hoped that the results of SAMS will contribute to fewer patients with indolent, low-risk prostate cancer receiving unnecessary treatment and more patients on active surveillance who need treatment receiving it when the disease is still curable. The less intensive investigational follow-up in the SAMS-FU trial would reduce the healthcare resources allocated to this large group of patients if it replaced the present standard schedule.
PMCID: PMC3810035  PMID: 23883427
biopsy; patient selection; prostatic neoplasm; randomized clinical trial; watchful waiting.

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