The experience of caregiver burden when being next of kin to a person with severe chronic obstructive pulmonary disease: A qualitative study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an inflammatory and irreversible lung disease. For next of kin caregiver burden can be a consequence of the situation of being close to a person affected by a chronic disease and in need of help. When there is an imbalance between stressors and resources to cope with the situation, caregiver burden emerges. Knowledge is sparse about how the caregiver burden is experienced by the next of kin. Therefore, the aim of this study is to identify and describe the caregiver burden experienced by next of kin of persons with severe COPD. METHOD: Qualitative interviews with 21 next of kin were conducted. Thematic analysis was used in accordance with the six steps of Braun and Clarke. RESULTS: The next of kin experience caregiver burden as 1) changed roles in daily life 2) putting life on hold 3) to stand aside. The next of kin are in need of support to manage daily life. CONCLUSIONS: The caregiver burden affect the next of kin physically and emotionally. To prevent advance consequences, person-centered care can be used to support the next of kin in the situation.

Simultaneous or staged resection of synchronous colorectal cancer liver metastases: a 13-year institutional follow-up.

BACKGROUND: This study compared postoperative outcomes and survival rates of patients who underwent simultaneous or staged resection for synchronous colorectal cancer liver metastases. METHODS: Between 2005 and 2018, 126 patients were registered prospectively at a university hospital in Sweden, 63 patients who underwent simultaneous resection were matched against 63 patients who underwent staged resection. RESULTS: The length of hospital stay was shorter for the simultaneous resection group, at 11 vs 16 days, p = <0.001. Fewer patients experienced recurrence in the simultaneous resection group 39 vs 50 patients, p = 0.012. There were no significant differences in disease-free survival and overall survival between the groups. Age (hazard ratio [HR] 1.72; 95% CI 1.01-2.94; p = 0.049) and Clavien-Dindo score (HR 2.22; 95% CI 1.06-4.67; p = 0.035) had impact on survival. CONCLUSION: Colorectal cancer with synchronous liver metastases can be resected simultaneously, and enables a shorter treatment time without jeopardizing oncological outcomes.

Evidence supporting a key role of Lp-PLA2-generated lysophosphatidylcholine in human atherosclerotic plaque inflammation.

OBJECTIVE: To determine whether the level of lysophosphatidylcholine (lysoPC) generated by lipoprotein-associated phospholipase A2 (Lp-PLA2) is associated with severity of inflammation in human atherosclerotic plaques. Elevated plasma Lp-PLA2 is associated with increased cardiovascular risk. Lp-PLA2 inhibition reduces atherosclerosis. Lp-PLA2 hydrolyzes low-density lipoprotein-oxidized phospholipids generating lysoPCs. According to in vitro studies, lysoPCs are proinflammatory but the association between their generation and plaque inflammation remains unknown. METHODS AND RESULTS: Inflammatory activity in carotid plaques (162 patients) was determined immunohistochemically and by analyzing cytokines in homogenates (multiplex immunoassay). LysoPCs were quantified using mass spectrometry and Lp-PLA2 and the lysoPC metabolite lysophosphatidic acid (LPA) by ELISA. There was a strong correlation among lysoPC 16:0, 18:0, 18:1, LPA, and Lp-PLA2 in plaques. LysoPC 16:0, 18:0, 18:1, LPA, and Lp-PLA2 correlated with interleukin-1ß, interleukin-6, monocyte chemoattractant protein-1, macrophage inflammatory protein-1ß, regulated on activation normal T-cell expressed and secreted, and tumor necrosis factor-α in plaques. High lysoPC and Lp-PLA2 correlated with increased plaque macrophages and lipids and with low content of smooth muscle cells, whereas LPA only correlated with plaque macrophages. Lp-PLA2, lysoPC 16:0, 18:0, and 18:1, but not LPA were higher in symptomatic than in asymptomatic plaques. CONCLUSIONS: The associations among Lp-PLA2, lysoPCs, LPA, and proinflammatory cytokines in human plaques suggest that lysoPCs play a key role in plaque inflammation and vulnerability. Our findings support Lp-PLA2 inhibition as a possible strategy for the prevention of cardiovascular disease.

The interaction between the patient and nurse anesthetist immediately before elective coronary artery bypass surgery.

PURPOSE: Establishing a purposive interaction with a patient who is in a vulnerable situation before coronary artery bypass graft (CABG) surgery poses a challenge for the nurse anesthetist. The aim of this study was to identify and describe the interaction between the patient and the nurse anesthetist immediately before elective CABG surgery. DESIGN: An observational study using a grounded theory design was used. METHODS: A theoretical selection of patients and nurse anesthetists was made. A total of 11 situations of patient/nurse anesthetist interaction were observed. The data were analyzed using the constant comparative method. FINDINGS: A core category of reassurance emerged from other categories of continuity, confirmation, and control. Continuity was characterized by expedient anesthesia nursing of high quality, confirmation was related to communication in a trusting atmosphere, and control was associated with skilled nursing interventions in the thoracic operating theatre. CONCLUSIONS: Reassurance can be achieved through a well-structured anesthesia nursing performance in the thoracic operating theatre, and by focusing on the patient and continuously giving him/her information during the preoperative preparation phase.

Chronic obstructive pulmonary diseasés impact on the affected person and next of kin: A mixed methods study.

OBJECTIVES: Severe chronic obstructive pulmonary disease affects and changes the lives of both affected persons and next of kin. There is a need for support and a sense of coherence to manage the life situation and minimize the symptom and caregiver burden. The aim of this study was to diverge or converge views of symptom burden, caregiver burden, the need for support, and sense of coherence in persons with chronic obstructive pulmonary disease and their next of kin to gain a deeper and broader knowledge and understanding. METHODS: A mixed methods study with data from interviews and four validated questionnaires from persons affected by chronic obstructive pulmonary disease in GOLD stages III and IV and their next of kin. RESULTS: Questionnaires from 112 persons affected by chronic obstructive pulmonary disease, and 71 next of kin, together with 25 and 21 interviews, show that; there is a difference between estimated symptoms and caregiver burden and experiences expressed in their own words. There is also a defect regarding meaningfulness, comprehensibility, and manageability affecting daily life. Symptoms and caregiver burden, together with the sense of coherence, strengthen the need for support. DISCUSSION: The complexity of the life situation leads to a need for supportive interventions to strengthen internal and external resources.

Postoperative recovery and its association with health-related quality of life among day surgery patients.

BACKGROUND: Day surgery holds advantages for both the patient and the health care organization. However, recovery beyond the first postoperative week and following different types of surgery has not been explored to any greater degree. The current aims were to prospectively describe postoperative recovery and health-related quality of life among different groups of day surgery patients and to explore the association between postoperative recovery and health-related quality of life 30 days after discharge. METHODS: A consecutive sample of 607 adult day surgery patients undergoing orthopaedic, gynaecological or general surgery was included. Postoperative recovery was assessed on days 1, 7 and 14 using the Swedish Post-discharge Surgery Recovery scale and the Quality of Recovery-23 scale. The EQ-5D was used to assess health-related quality of life preoperatively and 30 days following discharge. A repeated measure ANOVA was conducted to evaluate postoperative recovery from day 1 to day 14 and between different surgical groups. Hierarchical multiple linear regression models were used to explore the association between postoperative recovery and health-related quality of life. RESULTS: Postoperative recovery improved from day 1 to 14 in all surgical groups (p<0.001). The orthopaedic patients had lower postoperative recovery on day 14 compared to the general and the gynaecological patients (p<0.001). Health-related quality of life was lower among orthopaedic patients (p<0.001), even if significant improvements over time were seen in all groups. Recovery on day 7 was associated with health-related quality of life 30 days after the day surgery (p<0.05). CONCLUSION: Particularly orthopaedic day surgical patients seem to favour a closer follow-up in order to support recovery and thereby also positively influence health-related quality of life.

Low carotid calcium score is associated with higher levels of glycosaminoglycans, tumor necrosis factor-alpha, and parathyroid hormone in human carotid plaques.

BACKGROUND AND PURPOSE: Computed tomography (CT) is used to study coronary artery plaques, but little is known about its potential to characterize plaque composition. This study assesses the relation between carotid calcium score (CCS) by CT and plaque composition, namely extracellular matrix, inflammatory mediators, and calcium metabolites. METHODS: Thirty patients with significant carotid stenosis underwent preoperative CT. CCS was quantified by Agaston calcium score. Plaque components were studied histologically and biochemically (collagen, elastin, and glycosaminoglycans). Fraktalkine, interferon-γ, interleukin-10, interleukin-12 p70, interleukin-1ß, interleukin-6, monocyte chemoattractant protein-1, platelet-derived growth factor-AB/BB, RANTES and tumor necrosis factor-α, and parathyroid hormone were measured using Luminex technology. RESULTS: Plaques with CCS ≥400 had more calcium (P=0.012), less glycosaminoglycan (P=0.002), tumor necrosis factor-α (P=0.013), and parathyroid hormone (P=0.028) than those with CCS <400. CCS correlated with plaque content of calcium (r=0.62; P<0.001) and inversely with glycosaminoglycan (r=-0.49; P=0.006) and tumor necrosis factor-α (r=-0.56; P=0.001). CONCLUSIONS: Human carotid plaques with high CCS are richer in calcium and have lower amounts of glycosaminoglycan, parathyroid hormone, and tumor necrosis factor-α, which is one of the main proinflammatory cytokines involved in atherosclerosis. This suggests that CCS not only reflects the degree of calcification, but also other important biological components relevant for stability such as inflammation.

CD8+ T cell activation predominate early immune responses to hypercholesterolemia in Apoe⁻(/)⁻ mice.

BACKGROUND: It is well established that adaptive immune responses induced by hypercholesterolemia play an important role in the development of atherosclerosis, but the pathways involved remain to be fully characterized. In the present study we assessed immune responses to hypercholesterolemia induced by feeding Apoe-/- mice a high-fat diet for 4 or 8 weeks. RESULTS: The primary immune response in lymph nodes draining the aortic root was an increased expression of interferon (IFN)-γ in CD8(+)CD28(+) T cells, while an activation of IFN-γ expression in CD4(+) T cells was observed only after 8 weeks of high-fat diet. Contrarily, spleen CD4(+) T cells responded with a higher expression of IL-10. Spleen CD8(+) T cells expressed both IFN-γ and IL-10 and showed enhanced proliferation when exposed to Concanavalin A. Plasma levels of IgG and IgM against oxidized LDL did not change, but the level of apolipoprotein B/IgM immune complexes was increased. CONCLUSION: Hypercholesterolemia leads to unopposed activation of Th1 immune responses in lymph nodes draining atherosclerotic lesions, whereas Th1 activation in the spleen is balanced by a concomitant activation of Th2 cells. The activation of CD8(+) T cells implies that hypercholesterolemia is associated with formation of cell autoantigens.

Relation between personality and quality of postoperative recovery in day surgery patients.

BACKGROUND AND OBJECTIVE: Personality factors have been found to influence long-term postoperative depressive symptoms, health and distress in inpatients. To our knowledge, no studies have analysed whether the personality traits of day surgery patients relate to postoperative recovery. Hence, this study aims to explore possible relationships between personality traits and the quality of postoperative recovery in patients undergoing day surgery. METHODS: Our study used a consecutive sample of 260 day surgery patients to explore possible relationships between personal traits, measured by a short Big Five scale, and postoperative recovery, measured by modified Quality of Recovery-40, on postoperative days 1, 7 and 14. RESULTS: We found a positive correlation in changes of 'physical independence' and 'extroversion' (r = 0.20; P = 0.010) and 'intellect' (r = 0.18; P = 0.021) on postoperative days 1 and 7. These correlations were not observed on postoperative day 14. With regard to the change between days 7 and 14, correlations were found between 'physical interdependence' and 'agreeableness' and between 'physical interdependence' and 'conscientiousness' (r = -0.17; P = 0.028-0.030 for both). CONCLUSION: Day surgery patients appear to be a homogenous group with stable personalities, demonstrating some minor correlations between personality traits and the quality of postoperative recovery on days 1, 7 and 14. However, further studies are needed.

To live a life with COPD - the consequences of symptom burden.

Background: Chronic obstructive pulmonary disease (COPD) is a prevalent illness that, due to its symptoms and treatment, entails a significant burden for the affected person, and his/her family, health care and private finances. Today, knowledge and understanding are sparse regarding COPD-affected persons' own lived experiences and about the symptom burden and its effect on their daily life. Due to this knowledge gap the aim of this study was to identify and describe the symptom burden and its effect on daily life in people with COPD, based on their own lived experiences. Subject and method: Eleven males and 14 females in GOLD stages III and IV, in an age range of 58-82 years, were interviewed. An interview guide was used to direct the face-to-face interviews. Data was analyzed with thematic analysis following the six steps according to Braun and Clarke. Results: The results highlighted one theme: an altered everyday life. The altered everyday life leads to a need for support to handle everyday life and for different strategies to live as desired. Persons with COPD need to take each day as it comes and their life is not easy to plan since it depends on how they feel from day to day. Life is handled with several strategies such as breathing techniques, and ways to take care of the home and garden as well as the emotions. Support from the next of kin, society and the health care service is important. Conclusion: This study provides the insight that persons with COPD in stages III and IV have an altered life caused by the symptom burden. They must struggle with strategies to handle everyday life. There is a need of support from the next of kin and society to facilitate daily living, but this support needs to be well-balanced.

Differences between nurse and patient assessments on postoperative pain management in two hospitals.

RATIONALE: Differences between patient and professional assessments on pain and pain management have been reported, but no further analysis has described the statistical problems of pseudocorrelation concerning the nature of these differences. AIM: The aim of the present study was: (1) to investigate the differences between nurse and patient assessments of postoperative pain management in two hospitals, and (2) to discuss the nature and scope of these differences. METHOD: The subjects were 209 inpatients and 63 nurses from a central county hospital and 77 inpatients and 34 nurses from a university hospital. The 'Strategic and Clinical Quality Indicators in Postoperative Pain Management' questionnaire was used, comprising 14 items in four sub-scales (communication, action, trust and environment) and two questions concerning the worst pain experienced during the past 24 hours and general satisfaction. RESULT: Except for the trust sub-scale in one hospital, the correlations between patient and nurse ratings concerning all assessments were significant in both hospitals (r = 0.22-0.59). Both groups of patients had significantly higher (better) scores than judged by the nurses on the environment sub-scale and general satisfaction. In contrast, nurses from both hospitals tended to significantly underestimate patients' worst pain during the past 24 hours. Other differences between patient and nurse assessments were either non-significant or inconsistent between hospitals. Using so-called Oldham plots nurses tended to underestimate severe pain more often than mild pain, as judged by the patients, but this association was weak and statistically significant in one hospital only. CONCLUSION: Although the effects of pseudocorrelation are minimized by using Oldham plots, they are not cancelled. This issue is discussed, and we conclude that this study does not support the notion that the nurses tend to underestimate severe pain more often than mild pain.

AGR2, an endoplasmic reticulum protein, is secreted into the gastrointestinal mucus.

The MUC2 mucin is the major constituent of the two mucus layers in colon. Mice lacking the disulfide isomerase-like protein Agr2 have been shown to be more susceptible to colon inflammation. The Agr2(-/-) mice have less filled goblet cells and were now shown to have a poorly developed inner colon mucus layer. We could not show AGR2 covalently bound to recombinant MUC2 N- and C-termini as have previously been suggested. We found relatively high concentrations of Agr2 in secreted mucus throughout the murine gastrointestinal tract, suggesting that Agr2 may play extracellular roles. In tissue culture (CHO-K1) cells, AGR2 is normally not secreted. Replacement of the single Cys in AGR2 with Ser (C81S) allowed secretion, suggesting that modification of this Cys might provide a mechanism for circumventing the KTEL endoplasmic reticulum retention signal. In conclusion, these results suggest that AGR2 has both intracellular and extracellular effects in the intestine.

Postoperative recovery from the perspective of day surgery patients: a phenomenographic study.

BACKGROUND: Today, many patients undergo surgical procedures in a day surgery setting. The shift from inpatient care to care at the patients' own home following discharge places various demands on patients and their families during the recovery process. There is a need for knowledge of how the postoperative recovery process is perceived, as research indicates a lack of support for patients managing recovery at home. OBJECTIVE: To explore day surgery patients' different perceptions of postoperative recovery. DESIGN: A qualitative design with a phenomenographic approach was used. METHODS AND SETTINGS: Semi-structured interviews with 31 patients undergoing an orthopaedic, general or urologic day surgical procedure were carried out face to face at the patients' homes, 11-37 days post-discharge. Patients were recruited from two day surgery settings: one private unit and one unit associated with a local county hospital. RESULTS: The patients perceived postoperative recovery as comprising internal and external prerequisites and implying changes in ordinary life with varying levels of support. The effective production at the day surgery unit was perceived as having an impact on patients' prerequisites for recovery. The results are elucidated in three descriptive categories: 'Conditions for recovery at home', 'The rollback to ordinary life' and 'Being a cog in a flow of care'. CONCLUSIONS: The postoperative phase seems to be a weak link in day surgery care. From the patients' perspective, postoperative recovery following day surgery implies extensive responsibility at home. Patients need knowledge and understanding concerning what constitutes the normal range in recovery and how to manage self-care following their specific surgical procedure.

Mobilization of regulatory T cells in response to carotid injury does not influence subsequent neointima formation.

AIM: T cells have been attributed an important role in modulating repair responses following vascular injury. The aim of this study was to investigate the role of different T cell subsets in this context. METHODS AND RESULTS: A non-obstructive collar was introduced to inflict carotid artery injury in mice and subsequent activation of immune cells in draining lymph nodes and spleen were studied by flow cytometry. Carotid artery injury of wild type mice was associated with mobilization of both Th1 type CD4(+)IFNγ(+) and regulatory CD4(+)CD25(+)FoxP3(+) T cells in draining lymph nodes. Studies using FoxP3-green fluorescent protein (GFP) transgenic C57/Bl6 mice demonstrated scattered presence of regulatory T cells in the adventitial tissue of injured arteries as well as a massive emigration of regulatory T cells from the spleen in response to carotid injury. However, deletion of antigen presentation to CD4+ T cells (H2(0) mice), as well as deletion of regulatory T cells (through treatment with blocking anti-CD25 antibodies), did not affect neointima formation. Also deletion of antigen presentation to CD8(+) T cells (Tap1(0) mice) was without effect on carotid collar-induced neointima formation. CONCLUSION: The results demonstrate that carotid artery injury is associated with mobilization of regulatory T cells. Depletion of regulatory T cells does not, however, influence the subsequent repair processes leading to the formation of a neointima. The results also demonstrate that lack of CD8(+) T cells does not influence neointima formation in presence of functional CD4(+) T cells and B cells.

Elevated CD14++CD16- monocytes predict cardiovascular events.

BACKGROUND: Although monocytes in peripheral blood are no longer considered to be a homogeneous population, associations between distinct monocyte subsets and cardiovascular disease have not been highlighted in large epidemiological studies. METHODS AND RESULTS: The study included 700 randomly selected subjects from the cardiovascular arm of the Malmö Diet and Cancer study. Among these, 123 subjects experienced ischemic cardiovascular events during the follow-up until December 2008. Mononuclear leukocytes frozen at the baseline investigation in 1991 to 1994 were thawed and analyzed with flow cytometry to enumerate monocyte subsets, based on CD14 and CD16 expression. The percentage and number of classical CD14(++)CD16(-) monocytes were increased in the cardiovascular-event group compared with the event-free subjects (median, 69% [interquartile range, 62% to 76%] versus 67% [59% to 72%], P=0.017; 344 [251 to 419] cells/µL versus 297 [212 to 384] cells/µL, P=0.003). The hazard ratio was 1.66 for suffering a cardiovascular event in the highest tertile of the number of CD14(++)CD16(-) monocytes compared with the lowest tertile, even after adjustment for common risk factors (HR, 1.66; 95% CI: 1.02 to 2.72). CD14(++)CD16(-) monocytes did not, however, associate with the extent of atherosclerosis at baseline. In contrast, the percentage of monocytes expressing CD16 was negatively associated to the extent of carotid atherosclerosis measured as intima-media thickness at baseline. The chemokine receptors CCR2, CX3CR1, and CCR5 were not differentially expressed between cases and controls on any of the monocyte subsets, but CCR5 expression on CD14(+)CD16(++) monocytes was negatively associated to carotid intima-media thickness. CONCLUSIONS: This study shows that classical CD14(++)CD16(-) monocytes can predict future cardiovascular risk independently of other risk factors in a randomly selected population.

The vascular repair process after injury of the carotid artery is regulated by IL-1RI and MyD88 signalling.

AIM: The aim of this study was to determine whether innate immune signalling influences the vascular repair process in response to mechanical injury of arteries in mice. METHODS AND RESULTS: A non-obstructive collar was introduced around the carotid artery of MyD88-deficient mice, and neointima formation was compared with that observed in MyD88-competent mice. MyD88-deficient mice are characterized by impaired signal transduction from interleukin (IL)-1/IL-18 receptors and most Toll-like receptors (TLRs). The vascular response to injury was severely impaired in MyD88-deficient mice as neointima formation was not different from sham-operated mice, whereas MyD88-competent mice displayed robust neointima formation. Furthermore, infiltration of CD68-positive leucocytes was dependent on MyD88. During the early response to injury, 3 days after collar placement, a transient increase in the expression of TLR4 on vascular smooth muscle cells was observed. To determine the relative importance of IL-1 receptor and TLR4 activation in the vascular response to injury, mice were injected with blocking antibodies to these receptors prior to the collar placement. Neointima formation was reduced by 80% in mice administered IL-1RI blocking antibodies compared with mice given a control antibody, whereas administration of TLR4 blocking antibodies was without effect. CONCLUSION: These results show that inhibition of MyD88- or IL-1 receptor signalling reduces neointima formation in response to vascular injury and could offer therapeutic options for reducing clinical complications of excessive smooth muscle cell proliferation, such as that observed in in-stent restenosis.

Psychometric evaluation of the post-discharge surgical recovery scale.

UNLABELLED: RATIONALE, AIM AND OBJECTIVES: Day surgery patients are discharged after a short period of postoperative surveillance, and reliable and valid instruments for assessment at home are needed. The aim of this study was to evaluate the psychometric properties of a Swedish version of the post-discharge surgical recovery (PSR) scale, an instrument to monitor the patient's recovery after day surgery, in terms of data quality, internal consistency, dimensionality and responsiveness. METHODS: Data were collected on postoperative days 1 and 14 and included 525 patients. Data quality and internal consistency were evaluated using descriptive statistics, correlation analyses and Cronbach's alpha. The dimensionality of the scale was determined through an exploratory factor analysis. Responsiveness was evaluated using the standardized response mean and the area under the receiver operating characteristics curve (AUC). The correlation between change score in PSR and change score in self-rated health was assessed using Pearson's correlation coefficient. Patients' ability to work and their self-rated health on postoperative day 14 were used as external indicators of change. RESULTS: Six items showed floor or ceiling effects. Cronbach's coefficient alpha was 0.90 and the average inter-item correlation coefficient was 0.44 after the deletion of two items. The items were closely related to each other, and a one-factor solution was decided on. A robust ability to detect changes in recovery (standardized response mean = 1.14) was shown. The AUC for the entire scale was 0.60. When initial PSR scores were categorized into three intervals, the ability to detect improved and non-improved patients varied (AUC 0.58-0.81). There was a strong correlation between change scores in PSR and health (0.63). CONCLUSIONS: The Swedish version of the PSR scale demonstrates acceptable psychometric properties of data quality, internal consistency, dimensionality and responsiveness. In addition to previous findings, these results strengthen the PSR scale as a potential instrument of recovery at home.

Immune responses against aldehyde-modified laminin accelerate atherosclerosis in Apoe-/- mice.

BACKGROUND: LDL oxidation in the vascular wall is associated with aldehyde modification of surrounding extracellular matrix proteins that may target autoimmune responses against vascular tissues. Here we investigated the possible influence of immunity against a malondialdehyde (MDA)-modified form of the basement membrane protein laminin on atherosclerosis. METHODS AND RESULTS: IgM and IgG autoantibodies were present in human plasma and a prospective clinical study demonstrated that individuals who later suffered from acute cardiovascular events had lower levels of MDA-laminin antibodies compared to those in the control group. Immunohistochemical analysis of atherosclerotic plaques from Apoe-/- mice demonstrated co-localization between laminin and MDA epitopes, however MDA-laminin IgG was absent in mouse plasma. To determine the effect of MDA-laminin immunity, Apoe-/- mice were immunized with MDA-laminin. Analysis of circulating leukocytes at 12 weeks demonstrated increased T-cell activation, expansion of Th17 cells and a lower fraction of regulatory T cells (Tregs) in mice immunized with MDA-laminin. At 25 weeks, aortic atherosclerosis was increased by more than 60% in mice immunized with MDA-laminin, together with increased levels of MDA-laminin IgG1 and MDA-laminin-specific T-cells expressing IL-2, IL-4 and IL-6 in the spleen. CONCLUSION: The clinical observations suggest that immune responses against MDA-laminin may be involved in the development of cardiovascular disease in humans. Furthermore, observations in mice provide evidence for the presence of aldehyde-modified laminin in atherosclerotic lesions and demonstrate that induction of an immune response against these structures is associated with activation of Th17 cells, reduced fraction of Tregs and a more aggressive development of atherosclerosis.

Postoperative recovery: a concept analysis.

AIM: This paper presents a concept analysis of the phenomenon of postoperative recovery. BACKGROUND: Each year, millions of patients throughout the world undergo surgical procedures. Although postoperative recovery is commonly used as an outcome of surgery, it is difficult to identify a standard definition. METHOD: Walker and Avant's concept analysis approach was used. Literature retrieved from MEDLINE and CINAHL databases for English language papers published from 1982 to 2005 was used for the analysis. FINDINGS: The theoretical definition developed points out that postoperative recovery is an energy-requiring process of returning to normality and wholeness. It is defined by comparative standards, achieved by regaining control over physical, psychological, social and habitual functions, and results in a return to preoperative level of independence/dependency in activities of daily living and optimum level of psychological well-being. CONCLUSION: The concept of postoperative recovery lacks clarity, both in its meaning in relation to postoperative recovery to healthcare professionals in their care for surgical patients, and in the understanding of what researchers in this area really intend to investigate. The theoretical definition we have developed may be useful but needs to be further explored.