Ecological Grief and the Dual Process Model of Coping with Bereavement

The Dual Process Model of Coping with Bereavement (DPM, by Stroebe and Schut) is a well-known framework in contemporary grief research and counselling. It depicts how mourners oscillate between various tasks and reactions. There is a need to engage more with the intense feelings of loss (Loss-Oriented tasks), but also with other things in life and other parts of the adjustment process after a loss (Restoration-Oriented tasks). This interdisciplinary article applies the framework to ecological grief and extends it to collective levels. While the DPM has been broadened to family dynamics, many subjects of grief are even more collective and require mourning from whole communities or societies. Religious communities can play an important role in this. This article provides a new application called the DPM-EcoSocial and discusses the various tasks named in it, which are ultimately based on the grief researcher Worden’s work. The particularities of ecological grief are discussed, such as the complications caused by guilt dynamics, climate change denial, attribution differences about climate disasters, and nonfinite losses. Grief and grievance are intimately connected in ecological grief, and (religious) communities have important tasks for remembrance, mourning, and witness. The collective processes can lead to meaning reconstruction, transilience, and adversarial growth

Macrophage-mediated inflammation in the aseptic loosening of total hip replacements

Total hip replacement (THR) surgery is used to treat disabling end-stage arthritis disorders, and with recent advancements in implant materials, the outcomes of the operation are increasingly satisfactory. However, revision operations are commonly needed for conventional metal-on-polyethylene (MoP) prostheses and metal-on-metal (MoM) bearings due to adverse tissue reactions, periprosthetic osteolysis, and aseptic loosening. These conditions are driven by macrophage-dominated immune response to polyethylene (PE) and metal wear particles that derive primarily from the implant bearing surface and disperse along the bone-implant interface developing a chronic foreign body reaction. The aim of this thesis was to elucidate mechanisms of macrophage-mediated inflammation in the pathogenesis of aseptic loosening with an emphasis on conventional MoP implants. This knowledge is considered as a prerequisite for the development of THR into a better treatment. Since macrophage polarization has been found to determine wear particle responses, we characterized the production of macrophage polarizing cytokines in tissues surrounding aseptically loosened conventional MoP hip implants by using immunohistochemistry and qRT-PCR. Aseptic interface revealed increased gene expression of chemokines and osteoclast markers, but no convincing evidence for the presence of classical macrophage polarizing cytokines was detected. Therefore, this study suggests that macrophage polarization in periprosthetic tissues is primarily regulated by other local factors. To further clarify relationships among various inflammatory mediators in the interface tissue, we studied correlations between their gene expressions. Indeed, positive correlations were found between several pro-inflammatory cytokines and chemokines, but they showed no association with an underlying macrophage phenotype. Correlations were also studied between expression levels of inflammatory markers and life span of the implant. As an increased pro-inflammatory status correlated with shorter implant survival, these results underline the relevance of a complex inflammatory network in the pathogenetic cascade of aseptic loosening. The direct macrophage response to metal wear particles was analyzed in cell culture models using both murine and human macrophages. Since aging has multiple effects on macrophage function, we compared the particle-induced inflammatory response of macrophages obtained from the bone-marrow of genetically identical young (2-month) and aged (18-month) mice. Macrophages were polarized to M0, M1, or M2 phenotypes, challenged with titanium particles, and assessed for their production of inflammatory mediators by qRT-PCR and ELISA. Age-dependent secretion of inflammatory cytokines was verified also from particle-stimulated human primary macrophages. Questioning the contributory role of aging in particle-induced inflammation, no clear and constant differences were detected between the age groups. Nevertheless, M2 polarization effectively suppressed metal particle responses highlighting its potential to limit macrophage-mediated inflammation regardless of age. Although interleukin(IL)-1β has been identified as a key cytokine in the pathogenesis of aseptic loosening, its secretion remained absent from macrophages challenged with titanium particles. Therefore, we thoroughly characterized factors and molecular mechanisms leading to metal particle-induced activation of the NLRP3 inflammasome—an intracellular protein complex regulating IL-1β secretion. By challenging human primary macrophages with particles of titanium, chromium, and molybdenum, we observed that particles were capable of activating the NLRP3 inflammasome, but an additional priming signal was required to enable secretion of mature IL-1β. Besides bacterial lipopolysaccharide, we discovered that tumor necrosis factor as an alternative sterile agent could provide this co-stimulatory priming signal. These results indicate that the NLRP3 inflammasome mediates macrophage response to metal particles, and that particle-related IL-1β secretion can be induced under aseptic conditions without a contribution of bacterial components. In conclusion, this thesis suggests no contributory role for classical macrophage polarizing cytokines or aging per se in the pathogenesis of aseptic loosening but highlights a complex inflammatory reaction with active chemotaxis and enhanced osteoclast activity as an underlying feature. Induction of M2 polarization or inhibition of NLRP3 inflammasome appear as a means to suppress metal particle-induced inflammation and prevent development of aseptic osteolysis.Lonkan tekonivelleikkauksella hoidetaan loppuvaiheen nivelrikkoa, ja uusien tekonivelmateriaalien ansiosta leikkaustulokset ovat parantuneet erinomaisiksi. Perinteisissä metalli-muovi liukuparin sisältävissä tekolonkissa ja sittemmin käytöstä poistetuissa metalli-metalli lonkissa uusintaleikkauksia aiheuttaviksi ongelmiksi ovat kuitenkin muodostuneet haitalliset kudosreaktiot ja aseptinen irtoaminen, jossa tekonivelen komponentit menettävät kiinnityksensä ympäröivään luuhun. Nämä ilmiöt johtuvat pääasiassa tekonivelen liukupinnoilta irtoavista muovisista ja metallisista kulumapartikkeleista, jotka aktivoivat ympäröivien kudosten makrofageja saaden aikaan luukatoa edistävän kroonisen tulehdustilan. Tämän tutkimuksen tavoitteena oli selventää aseptiseen irtoamiseen liittyvän makrofagivälitteisen tulehduksen syntymekanismeja ja siten edistää tekolonkan kehittämistä yhä paremmaksi hoitomuodoksi. Koska makrofagien polarisaatiotila määrittää näiden vasteen kulumapartikkeleille, tutkimme makrofageja polarisoivien sytokiinien esiintymistä aseptisesti irronneiden metalli-muovi liukuparin tekolonkkien vieruskudoksesta geenimonistusreaktioin (PCR) ja immunovärjäyksin. Havaitsimme tulehduksellisten kemokiinien ja luunsyöjäsolujen ilmentymisen olevan koholla, mutta selkeää polarisoivien sytokiinien tuottoa ei todettu. Näin ollen makrofagien polarisaatiotilaa vaikuttaisivat ohjaavan ensisijaisesti muut tekijät. Kartoittaaksemme tarkemmin eri tulehdustekijöiden roolia ja keskinäisiä suhteita tekonivelen vieruskudoksessa analysoimme näiden ilmentymistasojen välisiä korrelaatioita sekä yhteyttä tekonivelen käyttöikään. Useiden tulehduksellisten sytokiinien ja kemokiinien tuotto korreloikin keskenään, mutta näiden välillä ei löytynyt yhteyttä makrofagien polarisaatiotilaa kuvaavien tekijöiden kanssa. Kohonnut tulehdustekijöiden tuotto sen sijaan korreloi aikaisempaan tekolonkan uusintaleikkauksen ajankohtaan. Nämä tulokset vahvistavat tulehdusreaktion merkitystä aseptisen irtoamisen kehittymisessä. Soluviljelymalleja käyttämällä tutkimme metallisten kulumapartikkelien suoraa vaikutusta sekä hiiren että ihmisen makrofageihin. Koska ikääntymisen on havaittu muuttavan makrofagien toimintaa, vertasimme kulumapartikkelien aiheuttamaa tulehdusvastetta geneettisesti identtisten nuorten (2 kk) ja vanhojen (18 kk) hiirten luuytimestä eristetyillä makrofageilla. Makrofagit erilaistettiin M0, M1 ja M2 polarisaatiotilaan ja altistettiin titaanipartikkeleille, minkä jälkeen näiden tuottamia tulehdustekijöitä mitattiin PCR- ja ELISA-määrityksillä. Iän vaikutusta partikkelien aiheuttamaan tulehduksellisten sytokiinien eritykseen arvioitiin myös ihmisistä eristetyillä makrofageilla. Kokonaisuudessaan ikäryhmien välillä ei havaittu selvää eroa, joten työn perusteella ikääntyminen itsessään ei merkittävästi vaikuta partikkelien aikaan saaman tulehdusreaktion voimakkuuteen. M2 polarisaatio kuitenkin tehokkaasti hillitsi partikkelivasteita iästä riippumatta, joten tämän edistäminen tekolonkan vieruskudoksessa saattaisi olla keino estää irtoamisreaktion kehittymistä. Vaikka interleukiini(IL)-1β on tunnistettu aseptisessa irtoamisessa keskeiseksi tulehdusta välittäväksi sytokiiniksi, emme havainneet tämän eritystä titaanipartikkeleille altistetuista makrofageista. Tämän vuoksi tutkimme tarkemmin metallipartikkelien kykyä aktivoida IL-1β:n eritystä säätelevää solunsisäistä signalointireittiä NLRP3 inflammasomia. Käsittelimme ihmisluovuttajien kokoverestä eristettyjä makrofageja titaani-, kromi- ja molybdeenipartikkeleilla ja havaitsimme, että partikkelit pystyvät aktivoimaan inflammasomia, mutta IL-1β:n eritys vaati partikkelien lisäksi toisen samanaikaisen aktivaatiosignaalin. Tällaisena IL-1β:n erityksen mahdollistavana niin sanottuna virityssignaalina toimi paitsi bakteerirakenne lipopolysakkaridi myös steriili tulehdussytokiini tuumorinekroositekijä (TNF). Tutkimus osoittaa, että NLRP3 inflammasomi välittää metallipartikkelien aikaan saamaa makrofagiaktivaatiota, ja että tämän käynnistämä IL-1β:n eritys on mahdollista aseptisissa olosuhteissa TNF-sytokiinin läsnä ollessa. Tutkimuksen perusteella makrofageja polarisoivat sytokiinit ja ikääntyminen itsessään eivät edistä aseptisen irtoamisen kehittymistä, mutta sen sijaan tämän taustasyynä vaikuttaa olevan monimuotoinen tulehdusreaktio yhdistettynä kohonneeseen kemokiinituotantoon ja luunsyöjäsolujen aktiivisuuteen. M2 polarisaation edistäminen tai NLRP3 inflammasomin estäminen vaikuttavat keinoilta ehkäistä kulumapartikkelien aikaansaamaa tulehdusvastetta ja siten tekolonkan irtoamisreaktion syntymistä.ei saavutettavaVäitöskirjan yhteenveto-osa on saavutettav

Early childhood lower-airway symptoms and airway hyperresponsiveness linked to school-age small-airway dysfunction

Background: The role of early airway hyperresponsiveness (AHR) in the subsequent small-airway lung function remains unclear. Objective: We assessed via a prospective follow-up study the small-airway lung function of schoolchildren with early childhood lower-airway symptoms and AHR to methacholine and compared the findings to the measurements of reference children with no previous or current lung diseases. Methods: During 2004-11, we measured atopic markers, lung function, and airway responsiveness to methacholine in 193 symptomatic children <3 years old. In 2016-18, a follow-up sample of 84 schoolchildren and 40 reference children were assessed for atopic parameters, spirometry, and small-airway lung function. Analysis was performed on the basis of early childhood AHR, early childhood atopy (defined as a positive skin prick test result), and exposure to parental smoking reported in a questionnaire. All the results were compared with those of the reference group. Results: Schoolchildren with early childhood lower-airway symptoms and AHR had higher prebronchodilator area under the reactance curve (AX) z score, lower forced expiratory flow at 50% of forced vital capacity (FEF50%) z score, and higher lung clearance index (LCI) 2.5% compared with those without early childhood AHR and reference children. Moreover, AX and FEF50% z scores only partly improved after bronchodilation. Early childhood atopy and exposure to parental smoking were not associated with school-age small-airway dysfunction. Conclusion: AHR in symptomatic young children associated with subsequent persistent small-airway dysfunction. Further studies with larger samples of symptomatic young children are warranted to determine whether this connection predicts the development of asthma or other obstructive pulmonary diseases as the children grow.Peer reviewe

Mining as environmentalism : green/grey extractivism and the production of extractive subjectivities around the Rio Tinto Kennecott mine in the United States

Concerted opposition from land defenders alongside climate change mitigation efforts by governments has made environmental and decarbonization efforts an essential element of mining operations. Located on the southwest outskirts of Salt Lake City, Utah, USA, Rio Tinto's Kennecott mine not only produces so-called 'energy transition materials,' but also emerges as an industry exemplar in advancing environmental mediation, modernization, and decarbonization strategies. Employing participant observation, drawing on 31 semi-structured interviews and 7 focus groups, this article explores the intersections between extractive subjectivities and green extractivism. While Rio Tinto's Kennecott mine ranks among the highest towards environmental, social, and governance standards, we argue that the more enlightened and self-reflective a mining company becomes the more it entrenches a damaging extractive subjectivity. Revealing techniques employed by the company, we demonstrate how 'enlightened' or green extractivist approaches prolong mining, delay transformative socioecological restoration and reinforce existing extractive subjectivities to produce grey extractivism.Peer reviewe

Extracellular vesicles, hyaluronic acid, and fatty acids in equine asthma

Equine asthma (EA) is an inflammatory condition of the lower airways that causes chronic respiratory dysfunction with varying degrees of severity. Recurrent episodes of bronchoconstriction and mucus accumulation in the airways lead to thickening of the airway walls. Horses with EA exhibit reduced respiratory capacity during exercise, and in severe cases, even at rest. A deeper understanding of EA’s molecular pathways is essential for developing biomarkers and treatments. Extracellular vesicles (EVs) are membrane-bound particles that participate in cell-to-cell communication. EVs transport biomolecules such as proteins, fatty acids, and hyaluronic acid (HA), influencing inflammation. EVs can mediate both favorable anti-inflammatory and unfavorable pro-inflammatory actions. Fatty acids serve as structural components for cells and EVs, and they are also precursors for inflammatory mediators. Lipid mediators play a vital role in inflammation and regulate the transition between the acute and resolution phases of inflammation. Similarly, HA, which can be carried by EVs, is involved in both inflammation and the maintenance of tissue health. Studying EVs, fatty acids, and HA together in the context of EA provides new insight into the complex molecular and cellular interactions in EA. This thesis examined EVs, fatty acids, HA, and airway remodeling in EA. The study confirmed the presence of EVs in bronchoalveolar lavage fluid (BALF) but found no significant differences in size or concentration between EA and control horses. Fatty acid profiles differed between horses with EA and control horses, but these profiles could not be used as diagnostic markers. In EVs, the proportion of palmitic acid (16:0) decreased, while that of eicosapentaenoic acid (20:5n-3) increased in horses with severe EA. In all sample types, the proportion of dihomo-γ-linolenic acid (20:3n-6) was elevated in horses with EA compared to controls. The study also revealed increased HA levels in BALF from EA horses. Additionally, severe EA was associated with airway remodeling. This research provides novel insights into the molecular interactions in EA, demonstrating that EVs, fatty acids, and HA contribute to airway inflammation and remodeling. Understanding these mechanisms advances clinical research in both veterinary and human asthma contexts.Hevosen astma on alempien hengitysteiden tulehduksellinen sairaus, jonka tarkka syntymekanismi on epäselvä. Astmaatikkohevosilla on yliherkät hengitystiet, jotka reagoivat ilmassa oleviin ärsykkeisiin, kuten pölyyn. Astmaattikkohevosten suorituskyky on heikentynyt, ja vakavassa tautimuodossa voi ilmetä hengitysvaikeuksia levossa. Astmaan johtavien tulehdusmekanismien tunteminen on tärkeässä roolissa uusien hoitomuotojen ja diagnostiikan kehittämisessä. Elimistön solut välittävät ympäristöönsä nanopartikkeleita, joita kutsutaan solunulkoisiksi vesikkeleiksi (extracellular vesicles). Vesikkelit osallistuvat solujen väliseen viestintään kuljettaen aktiivisia molekyylejä, kuten proteiineja, rasvahappoja ja hyaluronihappoa. Vesikkelit voivat vaikuttaa vastaanottavien solujen toimintaan ja siten muokata tulehdusreaktioita joko tulehdusta edistäen tai hilliten. Rasvahapot ovat vesikkeleiden ja solujen seinämien rakennusaineita. Lisäksi rasvahapoista valmistetaan useita tulehduksen kulkuun vaikuttavia välittäjäaineita. Keuhkokudoksessa on myös hyaluronihappoa, joka on tärkeä rakenteellinen osa soluväliaineessa ja toimii myös tulehdusvälittäjäaineen tavoin. Tulehduksessa erilaiset välittäjäaineet säätelevät sekä tulehduksen käynnistymistä että sen jälkeistä palautumista. Tämä väitöskirja selvitti vesikkeleiden, rasvahappojen ja hyaluronihapon roolia hevosen astmassa, mistä ei ole aikaisempaa tutkimustietoa. Tutkimus tuo uutta tietoa siitä, kuinka nämä biologisesti aktiiviset molekyylit osallistuvat hengitysteiden tulehdusreaktion syntyyn. Tutkimuksessa kehitettiin menetelmä vesikkeleiden eristämiseksi hevosten keuhkohuuhtelunäytteistä. Vesikkelinäytteissä havaittiin biologisesti aktiivisia rasvahappoja sekä hyaluronihappoa. Astmaatikkohevosilla ja kontrollihevosilla oli eroja keuhkohuuhtelunäytteiden ja vesikkeleiden rasvahappoprofiileissa, mutta rasvahappoprofiilia ei voitu käyttää astman diagnosoimisessa. Astmaatikkohevosilla vesikkeleissä havaittiin matalammat palmitiinihapon (16:0) osuudet ja korkeammat eikosapentaeenihapon (20:5n-3) sekä dihomo-γ-linoleenihapon (20:3n-6) osuudet verrattuna kontrollihevosiin. Tutkimuksessa todettiin astmaatikkohevosten keuhkohuuhtelunäytteiden hyaluronihapon määrän olevan korkeampi verrattuna kontrollihevosiin. Lisäksi hengitysteiden rakenteellisia muutoksia havaittiin vakavassa astmassa. Tutkimus osoitti, että hengitysteiden vesikkeli-, rasvahappo- ja hyaluronihappokoostumuksessa tapahtuu muutoksia hevosen astmassa ja että vesikkelit sekä niiden sisältö voivat vaikuttaa sairauden kulkuun. Tutkimuksesta saatu tieto on hyödyllistä pyrittäessä kehittämään uusia merkkiaineita ja hoitokeinoja sekä eläin- että ihmislääketieteessä.ei saavutettav

Measurement of the t t ¯ H and tH production rates in the H → b b ¯ decay channel using proton-proton collision data at s = 13 TeV

Abstract An analysis of the production of a Higgs boson (H) in association with a top quark-antiquark pair ( t t ¯ H ) or a single top quark (tH) is presented. The Higgs boson decay into a bottom quark-antiquark pair (H → b b ¯ ) is targeted, and three different final states of the top quark decays are considered, defined by the number of leptons (electrons or muons) in the event. The analysis utilises proton-proton collision data collected at the CERN LHC with the CMS experiment at s = 13 TeV in 2016–2018, which correspond to an integrated luminosity of 138 fb−1. The observed t t ¯ H production rate relative to the standard model expectation is 0.33 ± 0.26 = 0.33 ± 0.17(stat) ± 0.21(syst). Additionally, the t t ¯ H production rate is determined in intervals of Higgs boson transverse momentum. An upper limit at 95% confidence level is set on the tH production rate of 14.6 times the standard model prediction, with an expectation of 19.3 − 6.0 + 9.2 . Finally, constraints are derived on the strength and structure of the coupling between the Higgs boson and the top quark from simultaneous extraction of the t t ¯ H and tH production rates, and the results are combined with those obtained in other Higgs boson decay channels

Multi-isotopic evidence reveals the emergence of a cosmopolitan community at the Luistari cemetery in Eura, Finland, during the early Medieval period (600–1130 CE)

This study examines the role of the Eura region as a nexus linking the inland with Baltic Sea trade routes. Luistari cemetery, spanning from the early Merovingian to Medieval periods, provides key insights into South-Western Finland’s socio-economic structure and communication networks. Despite its significance, this burial community’s chronological dynamics and regional role remain poorly understood. Using multi-isotopic evidence contextualised with archaeological data, this research explores mobility and subsistence patterns among Luistari’s population. By delineating the bioavailable strontium range in the Eura region, the study assesses the local burial community’s mobility dynamics across various chronological phases. Identification of long- and short-distance migrants, discerned through strontium and carbon isotopes in conjunction with archaeological context, enhances understanding of Luistari within the regional and Circum-Baltic framework. Multi-isotopic evidence further aids in grasping local development within environmental and climatic contexts. Analysis of the strontium isotopic data patterns, combined with carbon and nitrogen, sheds light on settlement locations and subsistence strategies of the Luistari population. Notable transformations during the Viking I period (800–880 CE), marked by the establishment of a “founding” community, and shifts in dietary and migratory patterns in periods V II-III (880–1000 CE), indicate stabilisation of the local socio-economic conditions. Period V IV (1000–1070 CE) reveals connections, both maritime and continental, as the local community integrates into long-distance communication networks. The Final Period (1070–1130 CE) then shows only limited signs of mobility. The data suggest varied mobility patterns over the long-term development of the local community coupled with visibly changing subsistence strategies.Peer reviewe

Coagulation Profile of Convalescent Plasma Donors and Recipients

Convalescent plasma (CP) therapy for COVID-19 infection may have favorable safety but varying efficacy, with concerns about its procoagulant impact. We investigated whether administration of CP to hospitalized patients affects their coagulation profile. Fifty-four patients randomized in a double-blinded fashion received either placebo, low-titer CP (LCP) or high-titer CP (HCP). Donor blood samples were obtained at the time of the plasmapheresis, while recipient blood samples were collected before infusion, one day post-infusion and between two and six days after infusion. Routine laboratory follow-up, coagulation biomarkers, antiphospholipid antibodies, and thrombin generation (TG) were assessed. CP donors had normal blood cell counts and coagulation profiles, without differences between LCP and HCP donors at the baseline. All CP recipients were on low-molecular-weight heparin thromboprophylaxis at the time of the infusion. Despite randomization, the HCP group had lower baseline (p = 0.004) and Day 1 platelet counts (p = 0.019) than the LCP group. Von Willebrand antigen (VWF:Ag) levels clearly exceeded normal without differences at baseline. At Day 1, LCP recipients had higher VWF:Ag (mean +/- SD 224 +/- 15%) than HCP recipients (210 +/- 8%) (p = 0.012). In all groups, overall 80% lupus anticoagulant was positive. Baseline TG variables were comparable, but again LCP recipients exhibited higher endogenous thrombin potential (ETP) (1313 +/- 535 nM.min) (p = 0.038) and peak TG (184 +/- 106 nM) (p = 0.037) than the HCP group (870 +/- 425 nM.min and 86 +/- 54 nM). Our findings show that LCP increases VWF:Ag levels and enhances TG despite the thromboprophylaxis. These results suggest that HCP induces less hypercoagulability than LCP, which may contribute to the variability in CP efficacy.Peer reviewe

Vähähyötyisen hoidon karsiminen

As healthcare spending continues to rise, particularly in high-income countries, the concern over low-value care is growing. Low-value care refers to healthcare practices that do not provide meaningful benefits to patients. It causes direct harm to patients through adverse effects and costs. Additionally, low-value care presents an opportunity cost, as resources are no longer available for higher-value care and other critical needs, making it also a threat to the sustainability and quality of healthcare. Reliable estimates on the total prevalence of low-value care are lacking, but even 20-30% of care could be of low value to patients. De-implementation strategies aim to solve this problem by decreasing the use of low-value care and, as such, increasing the overall quality of care. We aimed to evaluate the current state of de-implementation intervention research, the effectiveness of various de-implementation strategies, and the barriers to de-implementation. First, we conducted a systematic scoping review of de-implementation randomized trials to map the current status of the literature and provide guidance for improving trial methodology. Our results, which included 227 de-implementation trials, indicated that the applicability of trial results is hindered by poor generalizability caused by context-specific and complex interventions, as well as a high risk of bias. To improve the quality of future research, we recommend simplifying intervention designs, increasing the number of clusters in cluster trials, and better controlling potential confounders. Second, guided by the scoping review, we conducted a systematic review and meta-analysis of de-implementation trials in primary care. Including 140 randomized trials in the analyses, we found moderate certainty evidence that provider education combined with audit and feedback decreases the use of low-value care (odds ratio 0.73 [95% confidence interval 0.63 to 0.84], -23% [-13% to -32%] relative decrease). Intervention combinations that included patient education resulted in potentially larger relative reductions of about 30-34% in low-value care; however, the evidence was of low certainty. Single-strategy interventions such as provider education, audit and feedback, and patient education resulted in only slight reductions in the use of low-value care, with the evidence quality rated as very low to low. Thus, multi-strategy interventions may be needed to have a meaningful impact. Third, we conducted a survey among primary care physicians in six high-income countries to evaluate their attitudes and obstacles to de-implementation. A total of 1,731 physicians responded (response rate 10.2%). Over 80% of physicians considered overtreatment and overdiagnosis as problems in healthcare, yet only about 50% felt the same about their own practice. The respondents perceived patient-related factors, such as patient requests and the expectation that something will be done, as important barriers to de-implementation, with over 80% rating them as at least moderately important. Similarly, physicians perceived lack of time and fear of medical errors as major barriers, with over 80% rating these as at least moderately important. Since multiple barriers are important to general practitioners and vary depending on the local context (e.g., countries), understanding these barriers locally is crucial when planning de-implementation strategies. Overall, healthcare administrators could prioritize de-implementation strategies combining audit and feedback with provider education, which have the strongest evidence base, and should consider whether a specific intervention is applicable in their setting. Furthermore, both low-certainty evidence from the systematic review and the survey results emphasize the importance of including the patient perspective in de-implementation strategies. This might involve improving shared decision-making tools and educating patients about the harms of low-value care and the natural progression of disease. Future research should focus on providing replicable and applicable evidence for these interventions.Vähähyötyinen hoito on kasvava ongelma etenkin länsimaisessa terveydenhuollossa. Sillä tarkoitetaan hoitokäytäntöjä jotka eivät tuo potilaalle merkittävää terveyshyötyä. Potilaille aiheutetun terveyshaitan ja kustannusten lisäksi se on uhka terveydenhuollon kestävyydelle. Käytöllä on rajallisten resurssien vuoksi myös vaihtoehtoiskustannus, joka tarkoittaa että suuremmassa hoidon tarpeessa oleva saattaa jäädä hoitamatta. De-implementaatiolla viitataan toimiin vähähyötyisen hoidon vähentämiseksi. Selvitimme väitöskirjan ensimmäisessä osassa de-implementaatiotutkimuksessa käytettyjä menetelmiä ja suunnittelimme systemaattiseen katsauksen ja meta-analyysin toteutusta. Löysimme 227 satunnaistettua de-implementaatiotutkimusta. Tutkimusten sovellettavuus oli heikkoa ja näin ollen interventioiden vaikutukset käytäntöön tuotuna epävarmoja, johtuen kontekstisidonnaisista ja monimutkaisista interventioista, sekä kohonneesta harhan riskistä. Tutkimuksen laadun parantamiseksi suosittelimme yksinkertaisempia interventioita, suurempia tutkimuskokoja ja tutkimustulosten yleistettävyyttä heikentävien sekoittavien tekijöiden huomiointia. Toisessa osassa arvioimme erilaisten de-implementaatiostrategioiden vaikutuksia vähähyötyisen hoidon käyttöön. Kohtalainen tutkimusnäyttö osoitti että lääkäreiden koulutus yhdistettynä auditointiin ja palautteenantoon vähentää vähähyötyisen hoidon käyttöä noin 23 prosenttia (95% luottamusväli -32% to -13%). Interventiot jotka sisälsivät potilaiden koulutusta sekä lisäksi jonkin muun strategian johtivat 30-34% vähenemiseen vähähyötyisen hoidon käytössä, mutta tutkimusnäyttö oli heikompaa ja täten vaikutuksen suuruuteen tulee suhtautua suuremmalla varauksella. Yhden strategian interventioilla oli vähäiset vaikutukset vähähyötyisen hoidon käyttöön ja näytön laatu heikkoa. Siten useampaa strategiaa yhdistävät interventiot saattavat olla usein tarpeen merkittävän vaikutuksen saavuttamiseksi. Viimeisessä osatyössä arvioimme kyselytutkimuksella perusterveydenhuollon lääkäreiden asenteita ja mielipiteitä de-implementaatioon liittyen. Toteutimme kyselyn kuudessa korkean tulotason maassa. Kyselyyn vastasi 1731 lääkäriä (vastausprosentti 10.2%). Yli 80 % lääkäreistä arvioivat ylidiagnostiikan ja ylihoidon merkittäviksi ongelmiksi oman maansa terveydenhuollossa, mutta vain 50 % omassa työskentelyssä. Yli 80 % lääkäreistä koki ajanpuutteen, työmäärän, virheiden pelon ja potilaaseen liittyvät tekijät vähintää kohtalaisen merkittäväksi esteeksi vähähyötyisestä hoidosta luopumiselle. Suuri esteiden määrä ja niiden paikallinen vaihtelu alleviivaa paikallisen esteiden selvittämisen tärkeyttä vähähyötyisen hoidon karsimista suunniteltaessa. Resurssit tulisi terveydenhuollossa kohdentaa ensisijaisesti interventioihin joista on vahvin tutkimusnäyttö. De-implementaation osalta se kohdistuu interventioihin jotka yhdistävät lääkärin koulutuksen ja palautteen annon. Luotettavien vaikutusten saavuttamiseksi tulisi ensisijaisesti käyttää interventioita jotka sopivat omaan kontekstiin ja ovat mahdollisia toteuttaa samaan tapaan kuin niitä on tutkittu. Sekä heikko tutkimusnäyttö systemaattisesta katsauksesta, että kyselytutkimus viittaavat siihen että, potilaat tulisi huomioida osana de-implementaation suunnittelua. Tämä tarkoittaa esimerkiksi työkaluja jaettuun päätöksentekoon, sekä potilaan informointia vähähyötyisen hoidon haitoista ja sairauksien luonnollisesta kulusta

Foggy fun : an exploration of mid-air gestural interaction with a fogscreen by children with attention-deficits

This study represents the first exploration of active gaming based on mid-air gestural interaction with a fogscreen, focusing on its feasibility for children with attention deficits. The aim was to evaluate the practicality and effectiveness of gestural interaction in two interaction scenarios involving translation and selection of objects projected on the fog, through the assessment of interaction performance and subjective opinions. The proposed approach was investigated in a custom-designed puzzle-based game Tangram. Eighteen novice participants, namely, children with confirmed attention deficits or attention-deficit/hyperactivity disorder (ADHD) played the game collaboratively in pairs during six sessions. Our results demonstrated that gestural interaction with the fogscreen in the Tangram game was not only enjoyable and engaging but also facilitated effective task completion, as shown by an 81% game success rate. During object translation, the participants typically needed two to three attempts to accurately relocate a puzzle piece, with 42% of translation movements adjusting the pieces' placements. Further, in object selection, it was underlined the importance of visual feedback corresponding to the user's hand position for effective interaction. These insights underscore the potential implications of gestural interfaces for fogscreen interaction in active gaming for children.Peer reviewe