Person-centred, nurse-led follow-up programme after surgical treatment for intermittent claudication

Intermittent Claudication (IC) is a common symptom of peripheral arterial disease with a prevalence of 5-10% among people 70 years of age or older. The symptoms of IC are discomfort or pain in the lower extremities, which is induced by exercise and relieved by short rest. Individuals with IC are burdened with chronic pain, fatigue, impaired walking ability and restricted mobility, and thereby negatively affected health related quality of life (HRQoL). Moreover, individuals with IC have high risk for cardiovascular events and mortality. Treatment of IC includes smoking secession, increased physical activity, medical treatment with lipid-modifying agents and antiplatelet agents, and surgical treatment when appropriate. Patients’ adherence to recommended lifestyle changes and medical treatment is a challenge, and 50% of all those with long-term medical therapy have poor adherence. It has been shown that health literacy as well as self-efficacy are associated with adherence. Intensified and person-centred care has been suggested to increase patients’ adherence. Person-centred care means involving the patient in their care as partners. The patient and the healthcare provider work together using the patients’ expertise in themselves as well as their life situation, and the healthcare providers’ expertise in the disease and treatment, to then develop a health plan for the patient jointly. The aim of this thesis was to evaluate if a person-centred, nurse-led follow-up programme, when compared to standard follow-up programme had an effect on: 1) Improving the patient’s adherence to medication (primary outcome) and reducing risk factors for cardiovascular disease (Paper II); 2) improving patients’ health related quality of life, health literacy and general self-efficacy (Paper III) and 3) Patients’ experience of receiving either of the programmes (Paper I and IV). The methods used were both qualitative and quantitative. Paper I was a qualitative interview study and the other three papers (II, III and IV) were quantitative studies evaluating a randomised controlled clinical trial (RCT), the FASTIC study, in which patients with IC were randomised to either person-centred, nurse-led follow-up or standard follow-up programme. The participants were scheduled for surgery at either of the two vascular surgery units in Stockholm and had given their written consent to participate. Data was then collected at baseline and 1 year after surgery on medication refills, risk factors for cardiovascular disease, HRQoL, health literacy, self-efficacy and patients’ perception of the quality of care provided using qualitative semi-structured interview (Paper I) registry for prescribed medication (Paper II) and self-reported questionnaires (Paper II, III and IV). A total of 318 patients were eligible, of those 214 were randomised and 204 analysed according to intention-to-treat. Results from Paper II showed that there was no difference in adherence to lipid-modifying agents or antiplatelet and/or anticoagulant agents between the groups receiving person-centred, nurse-led follow-up or standard follow-up programme at 1 year after surgery. Adherence was significantly overestimated when self-reported in comparison to registry data. The groups did not differ regarding predicted 10-year risk of cardiocerebrovascular events at 1 year after surgery. One risk factor, HbA1c, was significantly higher in the intervention group, however there was no difference in the change overtime. Those in the intervention group were more likely to quit smoking than in the control group but with no significance. Paper III showed that there were no significant differences between the groups regarding HRQoL, health literacy and self-efficacy. Inadequate health literacy was shown to be significantly associated with low HRQoL. In Paper I, the patients in both groups described that participation in follow-up programmes after surgery was a positive experience leading to increased awareness of their own health. The intervention group described that the person-centred care was important for maintaining healthy lifestyle changes. Paper IV showed that the patients in the intervention group tended to perceive the quality of care more satisfactory than the control group, with significant differences in some aspects such as information about self-care. In conclusion, person-centred, nurse-led follow-up programme did not improve adherence to medication; had similar effect on HRQoL, health literacy and self-efficacy, and was more likely perceived as satisfactory in some aspects of quality of care when compared with standard follow-up programme

Polycyclic Aromatic Hydrocarbons in Electrocautery Smoke during Peritonectomy Procedures

Objective. This study identified and quantified polycyclic aromatic hydrocarbons (PAHs) in electrocautery smoke during 40 peritonectomy procedures and investigated any correlations and/or differences between levels of PAHs and perioperative variables. Methods. PAHs were measured in personal and stationary sampling by 40 mm Millipore cassettes, for adsorption of both gaseous and particle-bound PAHs. Results. All 16 USEPA priority pollutant PAHs were detected during peritonectomy procedures, naphthalene being the most abundant. For the only two PAHs with Swedish occupational exposure limits (OELs), benzo[a]pyrene and naphthalene, limits were never exceeded. Amount of bleeding was the only perioperative variable that correlated with levels of PAHs. Conclusions. Low levels of PAHs were detected in electrocautery smoke during peritonectomy procedures, and an increased amount of bleeding correlated with higher levels of PAHs. For evaluation of long-term health effects, more studies are needed

Exploring the Agriculture-Nutrition Linkage in Northern Ghana

Despite progresses over the last few decades, undernutrition is widespread across Africa south of the Sahara. While agricultural interventions have traditionally focused on enhancing yields of few staple crops, there is increased interest on the role of production diversity in enhancing the dietary quality of subsistence farm households. This study examines the effects of on-farm production diversity and productivity on household dietary diversity using primary data from Ghana, where a sustainable intensification program is being implemented. In addition, it assesses possible heterogeneity in the effect of production diversity by market access. Identification is based on instrumental variables ‒ to account for possible simultaneity between production and consumption decisions ‒ and propensity score weighting‒to account for potential self-selection into the program. Both productivity and production diversity positively affect dietary diversity, with the effect of the latter getting stronger the farther away the daily market is, suggesting the importance of production diversity in settings with limited access to markets

Polycyclic Aromatic Hydrocarbons in Electrocautery Smoke during Peritonectomy Procedures

Objective. This study identified and quantified polycyclic aromatic hydrocarbons (PAHs) in electrocautery smoke during 40 peritonectomy procedures and investigated any correlations and/or differences between levels of PAHs and perioperative variables. Methods. PAHs were measured in personal and stationary sampling by 40 mm Millipore cassettes, for adsorption of both gaseous and particle-bound PAHs. Results. All 16 USEPA priority pollutant PAHs were detected during peritonectomy procedures, naphthalene being the most abundant. For the only two PAHs with Swedish occupational exposure limits (OELs), benzo[a]pyrene and naphthalene, limits were never exceeded. Amount of bleeding was the only perioperative variable that correlated with levels of PAHs. Conclusions. Low levels of PAHs were detected in electrocautery smoke during peritonectomy procedures, and an increased amount of bleeding correlated with higher levels of PAHs. For evaluation of long-term health effects, more studies are needed

Platinum-decorated carbon nanotubes for hydrogen oxidation and proton reduction in solid acid electrochemical cells

Pt-decorated carbon nanotubes (Pt-CNTs) were used to enhance proton reduction and hydrogen evolution in solid acid electrochemical cells based on the proton-conducting electrolyte CsH_2PO_4. The carbon nanotubes served as interconnects to the current collector and as a platform for interaction between the Pt and CsH_2PO_4, ensuring minimal catalyst isolation and a large number density of active sites. Particle size matching was achieved by using electrospray deposition to form sub-micron to nanometric CsH_2PO_4. A porous composite electrode was fabricated from electrospray deposition of a solution of Pt-CNTs and CsH_2PO_4. Using AC impedance spectroscopy and cyclic voltammetry, the total electrode overpotential corresponding to proton reduction and hydrogen oxidation of the most active electrodes containing just 0.014 mg cm^(−1) of Pt was found to be 0.1 V (or 0.05 V per electrode) at a current density of 42 mA cm^(−2) for a measurement temperature of 240 °C and a hydrogen-steam atmosphere. The zero bias electrode impedance was 1.2 Ω cm2, corresponding to a Pt utilization of 61 S mg^(−1), a 3-fold improvement over state-of-the-art electrodes with a 50× decrease in Pt loading

Is Platinum Present in Blood and Urine from Treatment Givers during Hyperthermic Intraperitoneal Chemotherapy?

Background. In selected patients with peritoneal carcinomatosis (PC) originating from colorectal cancer (CRC) the high dosage of oxaliplatin (460 mg/m(2)) is recommended for hyperthermic intraperitoneal chemotherapy (HIPEC), which may be a health risk to those administering the drug. The aim of this study was to determine the risk of platinum (Pt) exposure for the two main people handling and administering the cytotoxic agent during HIPEC. Methods. Samples of blood and urine were collected from one male surgeon and one female perfusionist during oxaliplatin-based HIPEC treatment with open abdomen coliseum technique on six consecutive patients with PC from CRC. Results. All blood samples analysed were below the detection limit of <0.05 nmol/L Pt, and the urine samples were all below the detection limit of <0.03 nmol/L Pt. Conclusions. There appears to be little or no risk of Pt exposure during HIPEC when the recommended protective garment is used and the safety considerations are followed

Information and Competition in U.S. Forest Service Timber Auctions

This paper analyzes the role of private information in U.S. Forest Service timber auctions. In these auctions, firms bid a per unit price for each timber species. Total bids are computed by multiplying these prices by Forest Service volume estimates, but payments depend on actual volumes harvested. We develop an equilibrium theory for these auctions. We then relate (ex post) data about volume to (ex ante) bids. We show that bidders have private information about volumes of species and use it as predicted by theory. Differences in bidder estimates appear to affect the allocation of tracts, but competition limits information rents. We have benefited from the helpful comments of Pa

Hepatic acute-phase proteins control innate immune responses during infection by promoting myeloid-derived suppressor cell function

Acute-phase proteins (APPs) are an evolutionarily conserved family of proteins produced mainly in the liver in response to infection and inflammation. Despite vast pro- and antiinflammatory properties ascribed to individual APPs, their collective function during infections remains poorly defined. Using a mouse model of polymicrobial sepsis, we show that abrogation of APP production by hepatocyte-specific gp130 deletion, the signaling receptor shared by IL-6 family cytokines, strongly increased mortality despite normal bacterial clearance. Hepatic gp130 signaling through STAT3 was required to control systemic inflammation. Notably, hepatic gp130–STAT3 activation was also essential for mobilization and tissue accumulation of myeloid-derived suppressor cells (MDSCs), a cell population mainly known for antiinflammatory properties in cancer. MDSCs were critical to regulate innate inflammation, and their adoptive transfer efficiently protected gp130-deficient mice from sepsis-associated mortality. The hepatic APPs serum amyloid A and Cxcl1/KC cooperatively promoted MDSC mobilization, accumulation, and survival, and reversed dysregulated inflammation and restored survival of gp130-deficient mice. Thus, gp130-dependent communication between the liver and MDSCs through APPs controls inflammatory responses during infection

Global, regional, and national burden of osteoarthritis, 1990–2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021

Background Osteoarthritis is the most common form of arthritis in adults, characterised by chronic pain and loss of mobility. Osteoarthritis most frequently occurs after age 40 years and prevalence increases steeply with age. WHO has designated 2021–30 the decade of healthy ageing, which highlights the need to address diseases such as osteoarthritis, which strongly affect functional ability and quality of life. Osteoarthritis can coexist with, and negatively effect, other chronic conditions. Here we estimate the burden of hand, hip, knee, and other sites of osteoarthritis across geographies, age, sex, and time, with forecasts of prevalence to 2050. Methods In this systematic analysis for the Global Burden of Disease Study, osteoarthritis prevalence in 204 countries and territories from 1990 to 2020 was estimated using data from population-based surveys from 26 countries for knee osteoarthritis, 23 countries for hip osteoarthritis, 42 countries for hand osteoarthritis, and US insurance claims for all of the osteoarthritis sites, including the other types of osteoarthritis category. The reference case definition was symptomatic, radiographically confirmed osteoarthritis. Studies using alternative definitions from the reference case definition (for example self-reported osteoarthritis) were adjusted to reference using regression models. Osteoarthritis severity distribution was obtained from a pooled meta-analysis of sources using the Western Ontario and McMaster Universities Arthritis Index. Final prevalence estimates were multiplied by disability weights to calculate years lived with disability (YLDs). Prevalence was forecast to 2050 using a mixed-effects model. Findings Globally, 595 million (95% uncertainty interval 535–656) people had osteoarthritis in 2020, equal to 7·6% (95% UI 6·8–8·4) of the global population, and an increase of 132·2% (130·3–134·1) in total cases since 1990. Compared with 2020, cases of osteoarthritis are projected to increase 74·9% (59·4–89·9) for knee, 48·6% (35·9–67·1) for hand, 78·6% (57·7–105·3) for hip, and 95·1% (68·1–135·0) for other types of osteoarthritis by 2050. The global age-standardised rate of YLDs for total osteoarthritis was 255·0 YLDs (119·7–557·2) per 100 000 in 2020, a 9·5% (8·6–10·1) increase from 1990 (233·0 YLDs per 100 000, 109·3–510·8). For adults aged 70 years and older, osteoarthritis was the seventh ranked cause of YLDs. Age-standardised prevalence in 2020 was more than 5·5% in all world regions, ranging from 5677·4 (5029·8–6318·1) per 100 000 in southeast Asia to 8632·7 (7852·0–9469·1) per 100 000 in high-income Asia Pacific. Knee was the most common site for osteoarthritis. High BMI contributed to 20·4% (95% UI –1·7 to 36·6) of osteoarthritis. Potentially modifiable risk factors for osteoarthritis such as recreational injury prevention and occupational hazards have not yet been explored in GBD modelling. Interpretation Age-standardised YLDs attributable to osteoarthritis are continuing to rise and will lead to substantial increases in case numbers because of population growth and ageing, and because there is no effective cure for osteoarthritis. The demand on health systems for care of patients with osteoarthritis, including joint replacements, which are highly effective for late stage osteoarthritis in hips and knees, will rise in all regions, but might be out of reach and lead to further health inequity for individuals and countries unable to afford them. Much more can and should be done to prevent people getting to that late stage

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment