Leverage point themes within Dutch municipalities' healthy weight approaches: A qualitative study from a systems perspective.

INTRODUCTION: Despite all efforts of national and local approaches, obesity rates continue to rise worldwide. It is increasingly recognized that the complexity of obesity should be further addressed by incorporating a systems perspective when implementing approaches. Such an approach has four interconnected system levels: events, structures, goals, and beliefs, in which small changes ('leverage points') can lead to substantial changes in the functioning of the entire system. The current research examined the functioning of five Dutch municipalities' healthy weight approaches (HWAs) and the leverage point themes that can be identified in their system. METHODS: Thirty-four semi-structured interviews were conducted with various stakeholders about the HWA, including policy advisors, care professionals, practice professionals, and citizens. An inductive thematic analysis was performed. RESULTS: Three main themes were identified: 1) HWA organization structure, 2) collaboration between professionals, and 3) citizen participation. Across all system levels, we identified leverage point themes. The upper-levels events and structures occurred the most and were explained by underlying goals and beliefs. Leverage point themes regarding "HWA organization structure" were municipal processes, such as perceived impact; diversity of themes, activities, and tasks; network; and communication strategies, such as messages about the HWA. Leverage point themes regarding "collaboration between professionals" were linking pins, indicating central players within the network; motivation and commitment including support base; and stimulating one another to work on the HWA by spurring other professionals into action. Lastly, leverage point themes under "citizen participation" included reaching the target group, e.g., look for entry points; and citizens' motivation, including customization. DISCUSSION: This paper provides unique insights into HWAs' leverage point themes that can lead to substantial changes in how the entire system functions and makes suggestions about underlying leverage points to help stakeholders improve their HWA. Future research could focus on studying leverage points within leverage point themes

Ninety Cases of Craniocaudal Carotid Body Tumor Surgery; Should It Become the Standard Surgical Technique?

Vascular Surger

Contemporary Insertion of Central Venous Access Catheters in Pediatric Patients: A Retrospective Record Review Study of 538 Catheters in a Single Center

Analysis and support of clinical decision makin

Ninety Cases of Craniocaudal Carotid Body Tumor Surgery; Should It Become the Standard Surgical Technique?

Vascular Surger

Heat shock protein 90 protects rat mesenchymal stem cells against hypoxia and serum deprivation-induced apoptosis via the PI3K/Akt and ERK1/2 pathways*

Mesenchymal stem cell (MSC) transplantation has shown a therapeutic potential to repair the ischemic and infracted myocardium, but the effects are limited by the apoptosis and loss of donor cells in host cardiac microenvironment. The aim of this study is to explore the cytoprotection of heat shock protein 90 (Hsp90) against hypoxia and serum deprivation-induced apoptosis and the possible mechanisms in rat MSCs. Cell viability was determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Apoptosis was assessed by Hoechst 33258 nuclear staining and flow cytometric analysis with annexin V/PI staining. The gene expression of Toll-like receptor-4 (TLR-4) and V-erb-b2 erythroblastic leukemia viral oncogene homolog 2 (ErbB2) was detected by real-time polymerase chain reaction (PCR). The protein levels of cleaved caspase-3, Bcl-2, Bcl-xL, Bax, total-ERK, phospho-ERK, total-Akt, phospho-Akt, and Hsp90 were detected by Western blot. The production of nitric oxide was measured by spectrophotometric assay. Hsp90 improves MSC viability and protects MSCs against apoptosis induced by serum deprivation and hypoxia. The protective role of Hsp90 not only elevates Bcl-2/Bax and Bcl-xL/Bax expression and attenuates cleaved caspase-3 expression via down-regulating membrane TLR-4 and ErbB2 receptors and then activating their downstream PI3K/Akt and ERK1/2 pathways, but also enhances the paracrine effect of MSCs. These findings demonstrated a novel and effective treatment strategy against MSC apoptosis in cell transplantation

Saccular Abdominal Aortic Aneurysms Patient Characteristics, Clinical Presentation, Treatment, and Outcomes in the Netherlands

Objective: The aim of this was to analyze differences between saccularshaped abdominal aortic aneurysms (SaAAAs) and fusiform abdominal aortic aneurysms (FuAAAs) regarding patient characteristics, treatment, and outcome, to advise a threshold for intervention for SaAAAs.Background: Based on the assumption that SaAAAs are more prone to rupture, guidelines suggest early elective treatment. However, little is known about the natural history of SaAAAs and the threshold for intervention is not substantiated.Methods: Observational study including primary repairs of degenerative AAAs in the Netherlands between 2016 and 2018 in which the shape was registered, registered in the Dutch Surgical Aneurysm Audit (DSAA). Patients were stratified by urgency of surgery; elective versus acute (symptomatic/ruptured). Patient characteristics, treatment, and outcome were compared between SaAAAs and FuAAAs.Results: A total of 7659 primary AAA-patients were included, 6.1% (n = 471) SaAAAs and 93.9% (n = 7188) FuAAAs. There were 5945 elective patients (6.5% SaAAA) and 1714 acute (4.8% SaAAA). Acute SaAAApatients were more often female (28.9% vs 17.2%, P = 0.007) compared with acute FuAAA-patients. SaAAAs had smaller diameters than FuAAAs, in elective (53.0mm vs 61 mm, P = 0.000) and acute (68mm vs 75 mm, P = 0.002) patients, even after adjusting for sex. In addition, 25.2% of acute SaAAA-patients presented with diameters <55mm and 8.4% <45 mm, versus 8.1% and 0.6% of acute FuAAA-patients (P = 0.000). Postoperative outcomes did not significantly differ between shapes in both elective and acute patients.Conclusions: SaAAAs become acute at smaller diameters than FuAAAs in DSAA patients. This study therefore supports the current idea that SaAAAs should be electively treated at smaller diameters than FuAAAs. The exact diameter threshold for elective treatment of SaAAAs is difficult to determine, but a diameter of 45mm seems to be an acceptable threshold.Vascular Surger