A holistic-existential approach to health promotion

Health promotion seems to be implicit in many nursing theories, but the theoretical and philosophical basis of health promotion in nursing is not always explicitly stated. The interpretation of health promotion is closely related to the interpretation of man, health, illness and nursing. There is a need to clarify, refine and redefine health promotion in nursing because the concept is partly nonspecific and has not been used to identify a distinctive nursing focus. The aim of this study was to formulate a stipulative definition of health promotive nursing with a holistic-existential approach. A philosophical frame of reference in combination with conceptual analysis and theoretical synthesis were used as the methodological approach. The philosophical framework served as a basis in selecting the nursing theories and influenced the analysis. Two nursing theories and one nursing model were selected due to their influence on Norwegian nursing and because of their philosophical basis. Through analysis and synthesis of the selected nursing theories, the concepts man, health, illness/disease and nursing were analysed. The paper proposes a stipulative definition of health promotion in nursing based on a holistic-existential approach, supported by five necessary conditions. The definition and conditions needs to be further investigated by both empirical studies and by comparing with other relevant nursing theories, in order to formulate theoretical statements. The proposed definition may be the first step in a process of developing a theoretical framework of health promotive nursing with a holistic-existential approach.     

Reduced expression of both Bax and Bcl-2 is independently associated with lymph node metastasis in human breast carcinomas

Imbalance between pro-apoptotic and anti-apoptotic proteins, causing altered apoptosis, may lead to tumour development and tumour progression, and reduced response to adjuvant therapy. In this study, we evaluated the expression patterns of Bcl-2, Bcl-xL, and Bax protein in 126 primary invasive breast carcinomas, and the association with other clinicopathological parameters. We used immunohistochemical methods to evaluate protein expression. Reduced expression of both Bax and Bcl-2 was associated with lymphnode metastases in univariate analyses (one-way ANOVA) as well as in multivariate analysis (binary logistic regression) (Bcl-2 p=0.003 univariate, p=0.01 multivariate, Bax p=0.05 univariate, p=0.03 multivariate). Bcl-2 overexpression showed an inverse association with cyclin A (p=0.05), while expression of Bcl-xL showed an association only with cyclin D3 (p=0.04). Bcl-xL expression also showed a highly significant association with oestrogen receptor status (p=0.009). Bcl-2 and Bcl-xL showed an association with different D-type cyclins, indicating different pathways of pathogenesis. Expression of Bcl-2 was associated with better patient survival in univariate analysis (Kaplan meyer p=0.04), but lost its prognostic value in multivariate analysis (Cox regression p=0.2).     

Heparin-coated circuits (Duraflo II) with reduced versus full anticoagulation during coronary artery bypass surgery

BACKGROUND: Introduction of completely heparin-coated cardiopulmonary bypass (CPB) circuits combined with reduced systemic anticoagulation has been shown to reduce postoperative bleeding and requirements for allogeneic transfusions after cardiac surgery. However, some uncertainty exists whether this effect is due to the reduced amount of heparin or to the heparinized surface itself. Therefore, a retrospective study was undertaken, comparing two different anticoagulation protocols applied to coronary artery bypass patients treated with identical heparin-coated CPB equipment. METHOD: Over a 12 month period all coronary artery bypass patients operated with extracorporeal circulation were subjected to a Duraflo II heparin-coated circuit (Baxter Healthcare Corp, Bentley Laboratories Division, Irvine, Calif) and full heparin dose (activated clotting time [ACT] > 480 seconds; Group F, n = 651). Over the next 24 months, all coronary patients who were treated with an identical circuit combined with reduced systemic heparinization (ACT > 250 seconds) were included in Group R (n = 675). Except for the different anticoagulation protocols, all treatment regimens before, during, and after the operation remained unchanged throughout the study period. RESULTS: There were no statistically significant differences in any major demographic or operative parameters. In Group R, the postoperative bleeding was mean 665 +/- 257 ml versus 757 +/- 367 ml in Group F (p < 0.0001), and the perioperative decrease in hemoglobin concentration was significantly lower in Group R (22 +/- 1.2 gm/L versus 25 +/- 1.3 gm/L, p < 0.0001). The time for postoperative ventilatory support was shorter in Group R (1.7 +/- 1.3 hours versus 1.9 +/- 1.1 hours in Group F, p = 0.0006), and the incidence of new episodes of atrial fibrillation after the operation was lower (26.4% in Group R versus 32.8% in Group F, p = 0.01). There were no significant differences in the incidences of perioperative myocardial infarction, stroke, transient neurological disturbances, physical rehabilitation, or mortality. No technical or coagulation problems were recorded in either group. CONCLUSION: The use of Duraflo II coated circuits for CPB combined with reduced anticoagulation decrease postoperative bleeding and hemoglobin loss compared with full heparin dose treatment. In addition, the intubation time was shorter and the incidence of postoperative atrial fibrillation was lower in the patients treated with low heparin doses.     

Heparin-coated circuits and reduced systemic anticoagulation applied to 2500 consecutive first-time coronary artery bypass grafting procedures

BACKGROUND: In contrast to the widespread popularity of off-pump techniques for coronary artery bypass grafting, our institution has chosen a different strategy, emphasizing improvements in the technology for extracorporeal circulation, as well as simplifying surgical and clinical management. The clinical short-term results of this approach were analyzed. METHODS: The on-pump strategy includes routine use of heparin-coated circuits combined with low systemic heparinization (activated coagulation time of more than 250 seconds), intention of total revascularization within limited ischemic times and pump times, minimal use of blood transfusions, early extubation, and rapid postoperative recovery. The data from the first 2,500 consecutive first-time coronary artery bypass grafting patients (January 1998 to February 2002) treated with this protocol were retrospectively analyzed. RESULTS: There were 487 female (median age 68 years) and 2013 male (median age 64 years) patients. A median of four (one to nine) (mean 4.5 +/- 1.2) distal anastomoses were created, and the median aortic cross-clamp time and pump time were 34 and 54 minutes, respectively. At least one internal mammary artery was used in 99.7% of the patients. Blood or bank blood products were given to 118 patients (4.7%). Median extubation time was 1.5 hours. The stroke rate was 0.8%, transient neurologic deficits occurred in 0.6% of the patients, and the incidence of perioperative myocardial infarction was 1.1%. By the fifth day, 91% of the patients were ready for discharge. Seven patients (0.28%) died during their hospital stay. CONCLUSIONS: Coronary artery bypass grafting with heparin-coated cardiopulmonary bypass circuits and reduced systemic anticoagulation resulted in excellent clinical results, with minimal blood transfusions and rapid postoperative mobilization. The high number of grafted coronary arteries indicates complete revascularization in most patients, which is known to be a significant predictor of long-term event-free survival.     

Deductibles in Health Insurance: Pay or Pain?

We study a health-insurance market where individuals are offered coverage against both medical expenditures and losses in income due to illness. Individuals vary in their level of innate ability and their probability of falling ill. If there is private information about the probability of illness and an individual's innate ability is sufficiently low, we find that competitive insurance contracts yield screening partly in the form of co-payment, i.e., a deductible in pay, and partly in the form of reduced medical treatment, i.e., a deductible in pain.     

Complement activation directly induced by Helicobacter pylori

BACKGROUND AND AIMS: Helicobacter pylori is a frequent gram-negative colonizer of the human stomach. Its interaction with complement may be involved in the pathogenesis of chronic gastritis, and was mechanistically studied in vitro. METHODS: Four H. pylori strains, 2 cytotoxin-associated genes (cag)A+ and 2 cagA-, were isolated from infected patients. Bacteria or purified H. pylori lipopolysaccharides (LPSs) were incubated with nonimmune serum at 37 degrees C; the activation products C3b/iC3b/C3c (C3bc) and terminal complement complex (TCC) were then quantified by immunoassays. The serum sensitivity of 1 strain (L01, cagA+) was tested by counting the numbers of colony-forming units. RESULTS: All strains and LPSs generated large amounts of C3bc and TCC. Blocking of the classic complement pathway by the calcium chelator ethylene glycol tetraacetic acid (EGTA) markedly reduced the complement products, suggesting that H. pylori and its LPSs directly engage the classic activation pathway. H. pylori was shown to be serum sensitive, but 30% or more nonimmune serum was necessary to induce marked killing. After 5 minutes, swelled bacteria coated with C3bc and TCC were shown. CONCLUSIONS: H. pylori is complement sensitive and activates the classic pathway even in the absence of specific antibodies. Released cell wall constituents such as LPSs can activate complement and may explain why this bacterium induces gastric pathology without invading the mucosa.     

Probe calibration for freehand 3-D ultrasound

Ultrasound (US) probe calibration establishes the rigid body transformation between the US image and a tracking device attached to the probe. This is an important requirement for correct 3-D reconstruction of freehand US images and, thus, for accurate surgical navigation based on US. In this study, we evaluated three methods for probe calibration, based on a single-point phantom, a wire-cross phantom requiring 2-D alignment and a wire phantom for freehand scanning. The processing of acquired data is fairly common to these methods and, to a great extent, based on automated procedures. The evaluation is based on quality measures in 2-D and 3-D reconstructed data. With each of the three methods, we calibrated a linear-array probe, a phased-array sector probe and an intraoperative probe. The freehand method performed best, with a 3-D navigation accuracy of 0.6 mm for one of the probes. This indicates that clinical accuracy in the order of 1 mm may be achieved in US-based surgical navigation.     

Compensation claims after knee arthroplasty surgery in Norway 2008–2018

Background and purpose — Orthopedic surgery is one of the specialties with most compensation claims. We assessed the claims following knee arthroplasty surgery reported to the Norwegian System of Patient Injury Compensation (NPE) in light of institutional procedure volume.Patients and methods — We collected data from NPE and the Norwegian Arthroplasty Register (NAR) for the study period (2008–2018). Age, sex, type of claim, and reason for compensation were collected from NPE, while the number of arthroplasty surgeries was collected from NAR. The treating hospitals were grouped by quartiles according to annual procedure volume. The effect of hospital volume on the likelihood of an accepted claim was estimated.Results — NAR received 64,241 reports of arthroplasty procedures, of which 572 (0.9%) patients filed a claim for treatment injury. 55% of the claims were accepted, representing 0.5% of all knee arthroplasties. The most common reason for accepted claim was a hospital-acquired infection, in 28% of the patients, followed by misplaced implant (26%) and aseptic loosening (13%). The hospitals with the lowest annual volume (57 or fewer arthroplasties per year, first quarter) had a statistically significantly larger fraction of granted claims per procedures compared with other institutions.Interpretation — The overall risk of ending up with compensation due to treatment error following knee arthroplasty was 0.5%. The risk of accepted claim was greater for patients operated in the lowest volume hospitals.

The number of knee arthroplasty procedures in Norway has increased over the last decade and is now over 7,000 per year (Ackerman et al. 2017, NAR 2020). About 1 in 5 patients receiving a TKA remains dissatisfied with the result (Gunaratne et al. 2017). Although serious complications are rare, infections, implant loosening, misplaced implants, residual pain, and other complications do occur, with potential detrimental results. To monitor the safety of implants and define the epidemiology of the procedures, the Norwegian Arthroplasty Register (NAR) was established in 1987 (Havelin et al. 2000). NAR provides a comprehensive overview of knee arthroplasties taking place in Norway. Compliance with the registry is 97.6% for primary TKA and 93.2% for revisions (Wiik 2014).Patients who suffer an injury while receiving health services, within either the public or the private healthcare sector, can file a claim with the Norwegian System of Patient Injury Compensation (NPE). 3 criteria must be fulfilled for a claim to be accepted:

1. The injury must have been caused during health services (diagnosis, examination, treatment, care, or lack of such), even if no one is to blame. If the injury is severe and unexpected, compensation may be awarded even where no error or omission in treatment has occurred (for example if infection occurs despite adequate prophylaxis).
2. The injury must have caused financial loss to the patient, except if the injury leads to permanent medical impairment of more than 15%, in which case compensation might be awarded despite financial loss. This might be relevant for retired patients or for patients who can continue to work in spite of the disability.
3. The patient must file a claim within a reasonable time (currently set at 3 years) after the patient realizes that the injury is caused by the treatment or lack of treatment received. The claim is filed with NPE at no cost to the patient.

There is compelling evidence that low surgical volume increases the risk of complications and revision after knee arthroplasty surgery (Jaeschke et al. 1989, Badawy et al. 2013, Pamilo et al. 2015, Badawy et al. 2017). Whether this association is also true for injury compensation has not been studied. We evaluated the claims following primary and revision knee arthroplasty surgery filed with NPE and compared the findings with the results from NAR with a focus on annual hospital procedure volume.