Testing Cost Containment of Future Healthcare with Maintained or Improved Quality—The COSTCARES Project

Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies

Testing Cost Containment of Future Health Care with Maintained or Improved Quality – The COST CARES project Running title: Cost Containment of Future Health Care

Abstract Background Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross‐disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person‐centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies. Method In order to develop and test the roadmap, a COST Action project was initiated: COST−CARES, with 28 participating countries. This paper provides an overview of evidence about the effects of each of the identified enablers. Intersections between the drivers and the enablers are identified as critical for the success of future cost containment, in tandem with maintained or improved quality in healthcare. This will require further exploration through testing. Conclusion Cost containment of future healthcare, with maintained or improved quality, needs to be addressed through a concerted approach of testing key factors. We propose a framework for test lab design based on these drivers and enablers in different European countries

Harm and harm reduction in smokeless tobacco users. An in vitro and clinical study.

Background: This thesis describes the effects of smokeless tobacco (ST) and its derivatives on the oral mucosa; the development of, and results of applying a cessation program for snuff users with long and extensive exposure; and the persistent clinical and histomorphological changes after cessation. Methods: Three of the studies were open prospective non-randomized clinical intervention trials using nicotine replacement therapy (NRT) of either 4 mg nicotine chewing gum or 2 mg nicotine lozenges. Clinical examinations, biopsies, and histomorphological analyses were performed. In the fourth study in vitro assays were performed to investigate the effect of snuff extract, alkaloids, and selected tobacco-specific nitrosamines (TSNA) on the accessory function of rat oral epithelium cells and T cells. Results: Of 280 participants motivated to discontinue snuff use, 50 were selected to treatment. After 3, 6, and 12 months, 58%, 46%, and 30% respectively were tobacco abstinent. Compliance was confirmed by measuring cotinine and carbon monoxide (CO) levels. Four subjects were still on NRT after 12 months, but tobacco-free since baseline. Twenty subjects abstinent after 6 months had a second biopsy from the site of snuff application. Of these, 40% showed remaining clinical lesions, the most significant of which were seen in the 75% of subjects still using NRT. The histomorphological picture was dominated by reductions in epithelial thickness, keratinization, and inflammatory response after tobacco cessation, although 30% of subjects showed increased epithelial thickness and 35% had increased or constant inflammatory reaction. A shift from ortho- to parakeratinization was noted in 80% of lesions. Of 30 individuals who used lozenges for 6 months, 8 presenting lesions had a significantly higher nicotine exposure (p<0.05) than those without lesions. All lesions appeared between 1 and 6 weeks after treatment began. After 3 months of NRT, all lesions had resolved but one, which was healed at the 6-month control. In the mitogen (concanavallin A) driven in vitro model using rat oral epithelium cells with accessory Langerhans cells (LC), T cells incubated with various concentrations of extract of Swedish moist snuff (SS) showed a significant inhibition of cell proliferation at 12.5% (p<0.05), and a concentration of 4% reduced T cell proliferation by 50%. Alkaloids and TSNAs in concentrations similar to those in SS had no significant effect on cell proliferation. No mitogenic capacity was detected in the SS extract, alkaloids, or TSNA, although N′-nitrosonornicotine (NNN) showed a tendency to be stimulatory in an in vitro assay with T-cells and rat oral epithelial cells. Conclusion: Snuff cessation with NRT is a promising way to achieve a tobacco-free state. Compliance to treatment was high regardless of outcome, although almost all subjects gained weight, which correlated with a significant increase both in diastolic blood pressure in the success group and in total cholesterol values. Tissue samples from those with extensive exposure to snuff who were still using NRT on a daily basis 6 months after cessation were neither clinically nor histomorphologically completely normal. SS extract can evoke an immunosuppressive effect on T-cell proliferation using cells from oral epithelium as accessory cells. This effect was more pronounced when the complete SS extract was employed compared to when single components were used. These findings may indicate a local immunosuppressive effect of ST on the oral mucosa. Daily repeated sublingual exposure to nicotine for 3 months appears to be a safe form of administration with mild and transient effects in individuals devoid of clinical lesions

Patient-reported pain after surgical removal of leukoplakia : an observational 1-year follow-up study

Objective Oral leukoplakia (OL) presents as a white lesion of the oral mucosa and is not typically associated with the sensation of pain. OL should be surgically removed when possible because it is considered a potentially malignant oral disorder (PMOD). This study assessed the pain sensations experienced by patients in association with the occurrence and surgical treatment of OL. Methods Inclusion criteria were: a clinical diagnosis of OL; biopsy excision; and observation for at least 12 months in the ORA-LEU-CAN study. At the first visit, all the patients were asked about the occurrence of symptoms within the lesion. Ninety-four subjects were assessed over a period of 1 year. All patients underwent complete removal of OL. The patient cohort was divided into three sub-groups: (i) no pain before excision and at the 1-year follow-up; (ii) pain before excision; and (iii) pain at the 1-year follow-up. Results Overall, pain was reported by 21.3% of the patients at the study start whereas 13.8% of the patients reported pain 1 year after surgical treatment. Patient-reported pain from the lesion at study inclusion was significantly associated with lesions found on the lateral side of the tongue (p=.002). Pain reported by patients one year after surgery was significantly related to female gender (p=.038) and the presence of epithelial cell dysplasia (p=.022). Conclusion We conclude that surgical removal of OL results in a low risk of long-term post-surgical pain. However, OL located on the lateral side of the tongue and in OL with dysplasia are more likely to be associated with pain

Recurrence rates after surgical removal of oral leukoplakia : A prospective longitudinal multicentre study

Oral leukoplakia (OL) is a potentially malignant oral disorder. The Gold Standard treatment is to remove surgically the OL. Despite optimal surgery, the recurrence rates are estimated to be 30%. The reason for this is unknown. The aim of this study was to investigate the clinical factors that correlate with recurrence after surgical removal of OL. In a prospective study data were collected from 226 patients with OL. Forty-six patients were excluded due to incomplete records or concomitant presence of other oral mucosal diseases. Overall, 180 patients proceeded to analysis (94 women and 86 men; mean age, 62 years; age range, 28-92 years). Clinical data, such as gender, diagnosis (homogeneous/non-homogeneous leukoplakia), location, size, tobacco and alcohol use, verified histopathological diagnosis, and clinical photograph, were obtained. In patients who were eligible for surgery, the OL was surgically removed with a margin. To establish recurrence, a healthy mucosa between the surgery and recurrence had to be confirmed in the records or clinical photographs. Statistical analysis was performed with the level of significance set at P&lt;0.05. Of the 180 patients diagnosed with OL, 57% (N = 103) underwent surgical removal in toto. Recurrence was observed in 43 OL. The cumulative incidence of recurrence of OL was 45% after 4 years and 49% after 5 years. Fifty-six percent (N = 23) of the non-homogeneous type recurred. Among snuff-users 73% (N = 8) cases of OL recurred. A non-homogeneous type of OL and the use of snuff were significantly associated with recurrence after surgical excision (P = 0.021 and P = 0.003, respectively). Recurrence was also significantly associated with cancer transformation (P&lt; 0.001). No significant differences were found between recurrence and any of the following: dysplasia, site of lesion, size, multiple vs. solitary OL, gender, age, use of alcohol or smoking. In conclusion, clinical factors that predict recurrence of OL are non-homogeneous type and use of snuff

De stora restaureringarna : Från Uppsala domkyrka till Skokloster

De stora restaureringarna har varit årets tema. Genom att dokumentera och analysera teori och praktik i några av 1800- och 1900-talets största restaureringar - från genomgripande stilrestaureringar till ett mer återhållsamt och tekniskt skon­samt synsätt. Därmed får vi också ett bättre underlag även för dagens ställningsta­gande.Föremål för våra studier är Uppsala domkyrka, Gripsholms slott, Vreta kloster­kyrka, Gustav 11I:s paviljong i Haga, Kungapalatset i Vadstena och Skoklosters slott. Vi hoppas att denna utställning skall bidra till en kritisk hållning och en ökad kunskap om restaureringskonsten, som kvalificerad yrkesuppgift, tidsspegel för historiesyn och som gestaltningsideal.Restaureringskonsten handlar både om teori och praktik - att medvetet förhålla sig till det befintliga kulturarvet, hur och vad som skall bevaras, återställas och förnyas. I de stora restaureringarna har framstående arkitekter och antikvarier varit inblandade och resultatet av deras arbeten har blivit föremål för debatt, antingen i samtiden eller av eftervärlden. När vi idag ställs inför uppgiften att restaurera våra viktiga nationalmonument handlar det även om att ta ställning till tidigare gjorda restaureringar. Hur har synen på monumentens kulturhistoriska värde och metoder för restaurering varierat över tiden? Och hur ser vi på dessa frågor idag, när byggnaderna åter behöver restaureras? Avdelningen för Restaureringskonst vid Kungliga Konsthögskolan ger en ett­årig påbyggnadsutbildning, främst för arkitekter men även till byggnadsantikva­rier, ingenjörer och konservatorer med akademisk grundexamen och minst ett års yrkesverksamhet.</p

High-risk human papillomavirus in patients with oral leukoplakia and oral squamous cell carcinoma-A multi-centre study in Sweden, Brazil and Romania.

OBJECTIVES: Although causal associations between oral leukoplakia (OL), oral squamous cell carcinoma (OSCC) and high-risk human papillomavirus (HR-HPV) have been speculated upon in several reports, conclusive evidence has not been presented. This study investigates whether the number of cases of HR-HPV in OL has increased over time and whether the prevalence of HR-HPV-positive OL differs in various parts of the world. PATIENTS AND METHODS: A total of 432 patients with OL from Sweden, Brazil and Romania were analysed. Patients were divided into historical (1992-2002) and contemporary (2011-2017) cohorts from the respective countries. Seventeen patients with OL developed oral squamous cell carcinoma (OSCC). A real-time PCR assay, targeting HPV sub-types 6,11,16,18,31,33,35,39,45,52,56,58 and 59, was performed to detect HR-HPV in patients with OL. RESULTS: In the Swedish and Romanian cohorts, none of the investigated HPV sub-types were detected. In the Brazilian cohorts, five patients with OL (3%) were positive for HR-HPV, including four patients from the contemporary cohort (HPV 16, 31, 33) and one from the historical cohort (HPV 11). All the cases of OL that transformed into OSCC were HR-HPV-negative, as were the corresponding tumours. CONCLUSIONS: In summary, the prevalence of HR-HPV in OL is low in all the tested countries, and the incidence has not changed over time. HR-HPV in OL does not seem to be a driver of oncogenesis