Use of evidence-based approaches in procurement and implementation of health and welfare technologies - a survey among Swedish municipalities.

BACKGROUND: Health and welfare technologies (HWT) are increasingly procured and implemented by public providers in Swedish municipalities, but it remains unclear if and how evidence for these technologies' effectiveness is used in both processes. The aim of this study was to investigate the use of evidence in Swedish municipal public sector procurement and implementation of HWT. METHODS: A telephone survey of 197 municipalities was conducted with questions regarding the use of evidence in both processes, as well as eventual support needs regarding its use. Standard definitions of HWT and evidence were provided prior to the survey. Response frequencies and percentage proportions were calculated per question. Lambda (Λ) values with corresponding significance values were calculated for associations between responses to selected questions and the size and type of municipality, with values of 0.01 to 0.19 designated as weak associations, 0.20 to 0.39 as moderate, and 0.40 and above as strong. RESULTS: Sixty-four municipalities completed the entire survey. Consistent use of evidence for effectiveness of HWT occurred in less than half of respondents' municipal public procurement processes. Two-thirds of municipalities did not have an established model or process for implementation of HWT that used evidence in any manner. More than three quarters of municipalities lacked a systematic plan for follow-up and evaluation of effectiveness of implemented HWT, and of those that did less than half followed their plan consistently. Most municipalities expressed the need for support in using evidence in HWT-related processes but did not consider evidence and systematic evaluation to be prioritized. CONCLUSIONS: Weaknesses and gaps in using evidence in procurement and implementation processes may create a legacy of sub-optimal implementation of HWT in Swedish municipal health- and social care services, and lost opportunities for real-world evidence generation. There was a clear indication of the need for unified national guidance for using and generating evidence in key HWT-related municipal processes and implementation. Such guidance needs to be developed and effectively communicated.

Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) for non-epileptic seizures: a consecutive case series.

BACKGROUND: Research has demonstrated that implementation of Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) achieved full symptom remission in 93% of people with Functional Neurological Symptoms Disorder (FNSD), most of them exhibiting motor symptoms. The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD. This idea is transparently shared with people with FNSD in the form of telling them that their symptoms are caused by a nocebo effect, usually followed by some physical activity that aims to change the person's belief about their body. AIMS: To demonstrate that a version of NH-CBT can also be effective in eliminating or reducing non-epileptic seizures (assumed to be a sub-type of FNSD). METHOD: A consecutive case series design was employed. Participants were treated with NH-CBT over a 12-week period. The primary outcome measure was seizure frequency. Numerous secondary measures were employed, as well as a brief qualitative interview to explore participants' subjective experience of treatment. RESULTS: Seven out of the 10 participants became seizure free at least 2 weeks before their post-treatment assessment, and all stayed seizure-free for at least 5 months. Six of those seven remained seizure free at 6-month follow-up. There were large positive effect sizes for the majority of secondary measures assessed. CONCLUSIONS: This case series provides evidence of feasibility and likely utility of NH-CBT in reducing the frequency of non-epileptic seizures.

Evidence-related requirements in Swedish public sector procurement of health and welfare technologies - a systematic review.

BACKGROUND: Health and welfare technologies (HWT) are becoming increasingly employed in the Nordic countries, and in Sweden in particular. The amount of HWT public procurement is likely increasing at a similar rate, but requirements for evidence for effectiveness placed on bidders during this process may be lacking. METHOD: This study investigated the use of evidence as a requirement in public sector tendering process of HWT, and how it affected bidder attributes and procurement outcomes. A novel type of systematic review and content analysis of requests for tenders for HWT announced prior to June 2021 was therefore conducted in Swedish public procurement databases. RESULT: Ninety requests for tenders for 11 types of HWT met the inclusion criteria for review, accounting for potential contracts worth 246 to 296 million EUR. Criteria requiring evidence for effectiveness were used in 16 requests for tenders, accounting for 183 million EUR in potential contracts. Eight of the requests referred to an established independent standard to confirm such evidence, such as CE standard of conformity, MDR and/or MDD. This prevalence appears to cut across all types of procuring organisations and all types of HWT. The use of any evidence criteria, or lack thereof, does not appear to affect the outcomes of the tendering process. CONCLUSION: Criteria requiring evidence for effectiveness are used in less than a fifth of all public procurements of health- and welfare technologies in Sweden, and less than 10% refer to some form of independent standard as confirmation of such evidence. The procurement process therefore risks creating a legacy of sub-optimal technologies in health- and social care services. More prevalent and specific requirements for evidence and its continual generation in the procurement process are highly recommended. Recommendations for decision makers, procurement managers, and developers are provided.

Gray Literature in Evaluating Effectiveness in Digital Health and Health and Welfare Technology: A Source Worth Considering.

BACKGROUND: The need to assess the effectiveness and value of interventions involving digital health and health and welfare technologies is becoming increasingly important due to the rapidly growing development of these technologies and their areas of application. Systematic reviews of scientific literature are a mainstay of such assessment, but publications outside the realm of traditional scientific bibliographic databases-known as gray literature-are often not included. This is a disadvantage, particularly apparent in the health and welfare technology (HWT) domain. OBJECTIVE: The aim of this article is to investigate the significance of gray literature in digital health and HWT when reviewing literature. As an example, the impact of including gray literature to the result of two systematic reviews in HWT is examined. METHODS: In this paper, we identify, discuss, and suggest methods for including gray literature sources when evaluating effectiveness and appropriateness for different review types related to HWT. The analysis also includes established sources, search strategies, documentation, and reporting of searches, as well as bias and credibility assessment. The differences in comparison to scientific bibliographic databases are elucidated. We describe the results, challenges, and benefits of including gray literature in 2 examples of systematic reviews of HWT. RESULTS: In the 2 systematic reviews described in this paper, most included studies came from context-specific gray literature sources. Gray literature contributed to the overall result of the reviews and corresponded well with the reviews' aims. The assessed risk of bias of the included studies derived from gray literature was similar to the included studies from other types of sources. However, because of less standardized publication formats, assessing and extracting data from gray literature studies were more time-consuming and compiling statistical results was not possible. The search process for gray literature required more time and the reproducibility of gray literature searches were less certain due to more unstable publication platforms. CONCLUSIONS: Gray literature is particularly relevant for digital health and HWT but searches need to be conducted systematically and reported transparently. This way gray literature can broaden the range of studies, highlight context specificity, and decrease the publication bias of reviews of effectiveness of HWT. Thus, researchers conducting systematic reviews related to HWT should consider including gray literature based on a systematic approach.

Nocturnal digital surveillance in aged populations and its effects on health, welfare and social care provision: a systematic review.

BACKGROUND: Nocturnal digital surveillance technologies are being widely implemented as interventions for remotely monitoring elderly populations, and often replace person-based surveillance. Such interventions are often placed in care institutions or in the home, and monitored by qualified personnel or relatives, enabling more rapid and/or frequent assessment of the individual's need for assistance than through on-location visits. This systematic review summarized the effects of these surveillance technologies on health, welfare and social care provision outcomes in populations ≥ 50 years, compared to standard care. METHOD: Primary studies published 2005-2020 that assessed these technologies were identified in 11 databases of peer-reviewed literature and numerous grey literature sources. Initial screening, full-text screening, and citation searching steps yielded the studies included in the review. The Risk of Bias and ROBINS-I tools were used for quality assessment of the included studies. RESULT: Five studies out of 744 identified records met inclusion criteria. Health-related outcomes (e.g. accidents, 2 studies) and social care outcomes (e.g. staff burden, 4 studies) did not differ between interventions and standard care. Quality of life and affect showed improvement (1 study each), as did economic outcomes (1 study). The quality of studies was low however, with all studies possessing a high to critical risk of bias. CONCLUSIONS: We found little evidence for the benefit of nocturnal digital surveillance interventions as compared to standard care in several key outcomes. Higher quality intervention studies should be prioritized in future research to provide more reliable evidence.

Mobile Safety Alarms Based on GPS Technology in the Care of Older Adults: Systematic Review of Evidence Based on a General Evidence Framework for Digital Health Technologies.

BACKGROUND: GPS alarms aim to support users in independent activities. Previous systematic reviews have reported a lack of clear evidence of the effectiveness of GPS alarms for the health and welfare of users and their families and for social care provision. As GPS devices are currently being implemented in social care, it is important to investigate whether the evidence of their clinical effectiveness remains insufficient. Standardized evidence frameworks have been developed to ensure that new technologies are clinically effective and offer economic value. The frameworks for analyzing existing evidence of the clinical effectiveness of GPS devices can be used to identify the risks associated with their implementation and demonstrate key aspects of successful piloting or implementation. OBJECTIVE: The principal aim of this study is to provide an up-to-date systematic review of evidence based on existing studies of the effects of GPS alarms on health, welfare, and social provision in the care of older adults compared with non-GPS-based standard care. In addition, the study findings were assessed by using the evidence standards framework for digital health technologies (DHTs) established by the National Institute for Health and Care Excellence (NICE) in the United Kingdom. METHODS: This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Primary studies published in peer-reviewed journals and gray literature from January 2005 to August 2020 were identified through searches in 13 databases and several sources of gray literature. Included studies had individuals (aged ≥50 years) who were receiving social care for older adults or for persons with dementia; used GPS devices as an intervention; were performed in Canada, the United States, European Union, Singapore, Australia, New Zealand, Hong Kong, South Korea, or Japan; and addressed quantitative outcomes related to health, welfare, and social care. The study findings were analyzed by using the NICE framework requirements for active monitoring DHTs. RESULTS: Of the screened records, 1.6% (16/986) were included. Following the standards of the NICE framework, practice evidence was identified for the tier 1 categories Relevance to current pathways in health/social care system and Acceptability with users, and minimum evidence was identified for the tier 1 category Credibility with health, social care professionals. However, several evidence categories for tiers 1 and 2 could not be assessed, and no clear evidence demonstrating effectiveness could be identified. Thus, the evidence required for using DHTs to track patient location according to the NICE framework was insufficient. CONCLUSIONS: Evidence of the beneficial effects of GPS alarms on the health and welfare of older adults and social care provision remains insufficient. This review illustrated the application of the NICE framework in analyses of evidence, demonstrated successful piloting and acceptability with users of GPS devices, and identified implications for future research.

Sputum microbiomic clustering in asthma and chronic obstructive pulmonary disease reveals a Haemophilus-predominant subgroup.

BACKGROUND: Airway ecology is altered in asthma and chronic obstructive pulmonary disease (COPD). Anti-microbial interventions might have benefit in subgroups of airway disease. Differences in sputum microbial profiles at acute exacerbation of airways disease are reflected by the γProteobacteria:Firmicutes (γP:F) ratio. We hypothesized that sputum microbiomic clusters exist in stable airways disease, which can be differentiated by the sputum γP:F ratio. METHODS: Sputum samples were collected from 63 subjects with severe asthma and 78 subjects with moderate-to-severe COPD in a prospective single centre trial. Microbial profiles were obtained through 16S rRNA gene sequencing. Topological data analysis was used to visualize the data set and cluster analysis performed at genus level. Clinical characteristics and sputum inflammatory mediators were compared across the clusters. RESULTS: Two ecological clusters were identified across the combined airways disease population. The smaller cluster was predominantly COPD and was characterized by dominance of Haemophilus at genus level (n = 20), high γP:F ratio, increased H influenzae, low diversity measures and increased pro-inflammatory mediators when compared to the larger Haemophilus-low cluster (n = 121), in which Streptococcus demonstrated the highest relative abundance at the genus level. Similar clusters were identified within disease groups individually and the γP:F ratio consistently differentiated between clusters. CONCLUSION: Cluster analysis by airway ecology of asthma and COPD in stable state identified two subgroups differentiated according to dominance of Haemophilus. The γP:F ratio was able to distinguish the Haemophilus-high versus Haemophilus-low subgroups, whether the Haemophilus-high group might benefit from treatment strategies to modulate the airway ecology warrants further investigation.

A Novel Treatment Protocol (Nocebo Hypothesis Cognitive Behavioural Therapy; NH-CBT) for Functional Neurological Symptom Disorder/Conversion Disorder: A Retrospective Consecutive Case Series.

BACKGROUND: Theories concerning the aetiology of functional neurological symptom disorder (FNSD; also known as conversion disorder) have historically inferred that psychological factors or dissociative states underlie patients' symptoms. Current psychological models of functional neurological symptoms suggest that some type of 'top-down' representations/beliefs are activated automatically (without conscious awareness), leading to symptoms. It is assumed that these representations or beliefs are similar to the idea 'I am neurologically damaged', as in our clinical experience, almost all patients have some reason to doubt the integrity of their neurological system. AIMS: It was hypothesized that FNSD arises from a belief of being neurologically damaged (via a mechanism akin to a nocebo response), and an interdisciplinary treatment protocol was developed consistent with this hypothesis, transparently sharing this theory with participants. METHOD: A retrospective consecutive case series design was utilized, measuring functional independence and symptom remission. RESULTS: Of the 13 episodes of care, 12 resulted in complete or almost complete symptom remission. Length of stay in rehabilitation was also reduced compared with previous treatment attempts. CONCLUSIONS: It appears as if the treatment protocol may be very effective, and further controlled study appears warranted.

Outbreak of Foodborne Botulism in an Immigrant Community: Overcoming Delayed Disease Recognition, Ambiguous Epidemiologic Links, and Cultural Barriers to Identify the Cause.

We describe a botulism outbreak involving 4 Middle Eastern men complicated by delayed diagnosis, ambiguous epidemiologic links among patients, and illness onset dates inconsistent with a point-source exposure. Homemade turshi, a fermented vegetable dish, was the likely cause. Patients ate turshi at 2 locations on different days over 1 month.

Make me wanna holler: Meshell Ndegeocello, Black queer aesthetics, and feminist critiques.

This article examines the music and performance of Meshell Ndegeocello, arguing that they are part of a cross-Atlantic conversation that pushes the boundaries of Black feminist thought on masculinity and desire. From the time of her debut album in 1993, Ndegeocello has resisted categorization both in her public personae and in her music. Ndegeocello's refusal to be restricted in her stage performance and in her musical expression has created a rich text through which to read Black female masculinity. Her work has been particularly productive in rethinking (Black) feminist couplings of patriarchy with male anatomy. Ndegeocello's music challenges any one representation of female masculinity, mixing critiques of masculine privilege and violence with celebrations of pleasure and pansexual desire.

The Swedish national public health policy report 2010.

BACKGROUND: In 2003, the Swedish Parliament adopted a cross-sectorial national public health policy based on the social determinants of health, with an overarching aim--to create societal conditions that will ensure good health, on equal terms, for the entire population--and eleven objective domains. At that time the policy was globally unique, and serves as guidance for public health practice at the national, regional and local levels. The development of the public health policy and the determinants of health are presented regularly in various reports by the Swedish National Institute of Public Health. This supplement is a condensed version of the 174-page Public Health Policy Report 2010, the second produced since the national policy was adopted in 2003. METHODS: In order to provide a holistic approach to analysing implemented measures and providing new recommendations within the eleven objective domains of the Swedish national public health policy, we have divided these in three strategic areas. These are: Good Living Conditions, Health-Promoting Living Environments and Living Habits, and Alcohol, Illicit Drugs, Doping, Tobacco and Gambling, each described in the respective introductions for Chapters 3-5. The production of the report was supported by a common analytical model that clarified the societal prerequisites for health in the eleven objective domains. These are factors that can be influenced by political actions in order to create a change. Economic analyses have also been developed to provide a priority basis for political decisions. Analyses of the development of public health determinants were based on data from the National Public Health Survey and data delivered from about 15 various national agencies. Measures that have been implemented between 2004 and 2009 are analysed in details, as the basis for new recommendations for future measures. RESULTS: The introduction describes Swedish public health policy in the new millennium and how it has developed, the role of the Swedish National Institute of Public Health and other important stakeholders. Approaches, models and methods used in carrying out the commission to produce the public health policy report are also described. In the following chapters, the trends of important determinants of public health, in relation to the overarching aim and the 11 objective domains as grouped in the three strategic areas, are analysed. The final chapter presents the proposed prioritisation for the large number of recommendations that were made, and a presentation of the annual costs of ill health in Sweden. These are compared with the costs of implementing recommended measures. The final chapter also describes how the Public Health Policy Report 2010 was received and lists the recommendations that the Swedish Government has taken action on as of September 2012. CONCLUSIONS: Public health trends have generally been stable or positive, although health inequalities persist. Economic analyses demonstrate that ill-health in Sweden costs 12 billion SEK every year, yet a large amount of this ill-health can be prevented. Sixty-eight recommendations were presented in the report. The government's response to recommendations has been very positive; approximately 60% of the recommendations in the three strategic areas have been adopted less than two years after the Public Health Policy Report 2010 was published.

Shoe cleat position during cycling and its effect on subsequent running performance in triathletes.

Research with cyclists suggests a decreased load on the lower limbs by placing the shoe cleat more posteriorly, which may benefit subsequent running in a triathlon. This study investigated the effect of shoe cleat position during cycling on subsequent running. Following bike-run training sessions with both aft and traditional cleat positions, 13 well-trained triathletes completed a 30 min simulated draft-legal triathlon cycling leg, followed by a maximal 5 km run on two occasions, once with aft-placed and once with traditionally placed cleats. Oxygen consumption, breath frequency, heart rate, cadence and power output were measured during cycling, while heart rate, contact time, 200 m lap time and total time were measured during running. Cardiovascular measures did not differ between aft and traditional cleat placement during the cycling protocol. The 5 km run time was similar for aft and traditional cleat placement, at 1084 ± 80 s and 1072 ± 64 s, respectively, as was contact time during km 1 and 5, and heart rate and running speed for km 5 for the two cleat positions. Running speed during km 1 was 2.1% ± 1.8 faster (P < 0.05) for the traditional cleat placement. There are no beneficial effects of an aft cleat position on subsequent running in a short distance triathlon.

Obstacles to Evidence-Based Procurement, Implementation, and Evaluation of Health and Welfare Technologies in Swedish Municipalities: Mixed Methods Study.

BACKGROUND: Health and welfare technologies (HWTs) are interventions that aim at maintaining or promoting health, well-being, quality of life, and increasing efficiency in the service delivery system of welfare, social, and health care services, while improving the working conditions of the staff. Health and social care must be evidence-based according to national policy, but there are indications that evidence for HWT effectiveness is lacking in related Swedish municipal work processes. OBJECTIVE: This study aimed to investigate whether the evidence is used when Swedish municipalities procure, implement, and evaluate HWT, and if so, the kinds of evidence and the manner of their use. The study also aimed to identify if municipalities currently receive adequate support in using evidence for HWT, and if not, what support is desired. METHODS: An explanatory sequential mixed methods design was used with quantitative surveys and subsequent semistructured interviews with officials in 5 nationally designated "model" municipalities regarding HWT implementation and use. RESULTS: In the past 12 months, 4 of 5 municipalities had required some form of evidence during procurement processes, but the frequency of this varied and often consisted of references from other municipalities instead of other objective sources. Formulating requirements or requests for evidence during procurement was viewed as difficult, and gathered evidence was often only assessed by procurement administration personnel. In total, 2 of 5 municipalities used an established process for the implementation of HWT, and 3 of 5 had a plan for structured follow-up, but the use and dissemination of evidence within these were varying and often weakly integrated. Standardized processes for follow-up and evaluation across municipalities did not exist, and those processes used by individual municipalities were described as inadequate and difficult to follow. Most municipalities desired support for using evidence when procuring, establishing evaluation frameworks for, and following up effectiveness of HWT, while all municipalities suggested tools or methods for this kind of support. CONCLUSIONS: Structured use of evidence in procurement, implementation, and evaluation of HWT is inconsistent among municipalities, and internal and external dissemination of evidence for effectiveness is rare. This may establish a legacy of ineffective HWT in municipal settings. The results suggest that existing national agency guidance is not sufficient to meet current needs. New, more effective types of support to increase the use of evidence in critical phases of municipal procurement and implementation of HWT are recommended.

Digital Microlearning for Training and Competency Development of Older Adult Care Personnel: Mixed Methods Intervention Study to Assess Needs, Effectiveness, and Areas of Application.

BACKGROUND: Older adult care organizations face challenges today due to high personnel turnover and pandemic-related obstacles in conducting training and competence development programs in a time-sensitive and fit-for-purpose manner. Digital microlearning is a method that attempts to meet these challenges by more quickly adapting to the educational needs of organizations and individual employees in terms of time, place, urgency, and retention capacity more than the traditional competency development methods. OBJECTIVE: This study aimed to determine if and how an app-based digital microlearning intervention can meet older adult care organizations' personnel competency development needs in terms of knowledge retention and work performance. METHODS: This study assessed the use of a digital microlearning app, which was at the testing stage in the design thinking model among managerial (n=4) and operational (n=22) employees within 3 older adult care organizations. The app was used to conduct predetermined competency development courses for the staff. Baseline measurements included participants' previous training and competency development methods and participation, as well as perceived needs in terms of time, design, and channel. They then were introduced to and used a digital microlearning app to conduct 2 courses on one or more digital devices, schedules, and locations of their own choice during a period of ~1 month. The digital app and course content, perceived knowledge retention, and work performance and satisfaction were individually assessed via survey upon completion. The survey was complemented with 4 semistructured focus group interviews, which allowed participants (in total 16 individuals: 6 managerial-administrative employees and 10 operational employees) to describe their experiences with the app and its potential usefulness within their organizations. RESULTS: The proposed advantages of the digital microlearning app were largely confirmed by the participants' perceptions, particularly regarding the ease of use and accessibility, and efficiency and timeliness of knowledge delivery. Assessments were more positive among younger or less experienced employees with more diverse backgrounds. Participants expressed a positive inclination toward using the app, and suggestions provided regarding its potential development and broader use suggested a positive view of digitalization in general. CONCLUSIONS: Our results show that app-based digital microlearning appears to be an appropriate new method for providing personnel competency development within the older adult care setting. Its implementation in a larger sample can potentially provide more detailed insights regarding its intended effects.

Artificial Intelligence and Precision Health Through Lenses of Ethics and Social Determinants of Health: Protocol for a State-of-the-Art Literature Review.

BACKGROUND:  Precision health is a rapidly developing field, largely driven by the development of artificial intelligence (AI)-related solutions. AI facilitates complex analysis of numerous health data risk assessment, early detection of disease, and initiation of timely preventative health interventions that can be highly tailored to the individual. Despite such promise, ethical concerns arising from the rapid development and use of AI-related technologies have led to development of national and international frameworks to address responsible use of AI. OBJECTIVE:  We aimed to address research gaps and provide new knowledge regarding (1) examples of existing AI applications and what role they play regarding precision health, (2) what salient features can be used to categorize them, (3) what evidence exists for their effects on precision health outcomes, (4) how do these AI applications comply with established ethical and responsible framework, and (5) how these AI applications address equity and social determinants of health (SDOH). METHODS:  This protocol delineates a state-of-the-art literature review of novel AI-based applications in precision health. Published and unpublished studies were retrieved from 6 electronic databases. Articles included in this study were from the inception of the databases to January 2023. The review will encompass applications that use AI as a primary or supporting system or method when primarily applied for precision health purposes in human populations. It includes any geographical location or setting, including the internet, community-based, and acute or clinical settings, reporting clinical, behavioral, and psychosocial outcomes, including detection-, diagnosis-, promotion-, prevention-, management-, and treatment-related outcomes. RESULTS:   This is step 1 toward a full state-of-the-art literature review with data analyses, results, and discussion of findings, which will also be published. The anticipated consequences on equity from the perspective of SDOH will be analyzed. Keyword cluster relationships and analyses will be visualized to indicate which research foci are leading the development of the field and where research gaps exist. Results will be presented based on the data analysis plan that includes primary analyses, visualization of sources, and secondary analyses. Implications for future research and person-centered public health will be discussed. CONCLUSIONS:  Results from the review will potentially guide the continued development of AI applications, future research in reducing the knowledge gaps, and improvement of practice related to precision health. New insights regarding examples of existing AI applications, their salient features, their role regarding precision health, and the existing evidence that exists for their effects on precision health outcomes will be demonstrated. Additionally, a demonstration of how existing AI applications address equity and SDOH and comply with established ethical and responsible frameworks will be provided. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/40565.

Can the Millennium Development Goals database be used to measure the effects of globalisation on women's health in Sub-Saharan Africa? A critical analysis.

BACKGROUND: Africa has had poor returns from integration with world markets in globalisation, has experienced worsening poverty and malnutrition and has high burdens of HIV and communicable disease, with particular burdens on women. It is therefore essential to describe the impact of globalisation on women's health. Indicators such as the Millennium Development Goals (MDGs) are presented as having a major role in measuring this impact, but an assessment of the adequacy of aggregate national indicators used in monitoring the MDGs for this purpose is lacking. METHODS: The Millennium Development Goals' panel database 2000 to 2006 was used to investigate the association between globalisation and women's health in Sub-Saharan Africa based on various determinants of heath. Out of the 148 countries classified as developing countries, 48 were in Sub-Saharan Africa. RESULTS: Results suggest that developing countries are becoming more integrated with world markets through some lowering of trade barriers. At the same time, women's occupational roles are changing, which could affect their health status. However, it is difficult to measure the impact of globalisation on women's health from the MDG database. First, data on trade liberalization is aggregated at the regional level and does not hold any information on individual countries. Second, too few indicators in the MDG database are disaggregated by sex, making it difficult to separate the effects on women from those on men. CONCLUSIONS: The MDG database is not adequate to assess the effects of globalisation on women's health in Sub-Saharan Africa. We recommend that researchers aim to address this research question to find other data sources or turn to case studies. We hope that results from this study will stimulate research on globalisation and health using reliable sources.

Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT) for Persons With Functional Neurological Symptoms (Motor Type): Design and Implementation of a Randomized Active-Controlled Trial.

Introduction: Functional Neurological Symptom Disorders (FNSD) are associated with high levels of disability and immense direct and indirect health costs. An innovative interdisciplinary rehabilitation approach for individuals with functional neurological symptoms of motor type-Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT)-combines CBT and movement retraining with video feedback embedded in a comprehensive explanatory model of the etiology of FNSD. Methods: This protocol describes the development and implementation of a phase II, parallel group, randomized controlled trial with blinded outcome assessors to compare the efficacy of NH-CBT with an active control condition (supportive counseling and movement retraining). Individuals meeting diagnostic criteria of an FNSD or psychogenic movement disorder will be randomly assigned to one of the 8-week interventions. Self-report scales of motor and other physical symptoms, symptom-related psychological variables, and assessor ratings of participants' mobility will be administered at baseline, and at 8- and 16-week follow-up. Adverse events will be monitored across all sessions and therapeutic alliance will be measured at the end of therapy. The primary statistical analysis will test the hypothesis that NH-CBT is more effective than the control intervention at the 8-week follow-up. Discussion: The therapeutic strategies of NH-CBT are theory-driven by assumptions of the predictive coding model of the etiology of FNSD. Strengths and limitations of this trial will be discussed. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR; identifier: ACTRN12620000550909).

Hypoxia augments apnea-induced increase in hemoglobin concentration and hematocrit.

Increased hemoglobin concentration (Hb) and hematocrit (Hct), attributable to spleen contraction, raise blood gas storage capacity during apnea, but the mechanisms that trigger this response have not been clarified. We focused on the role of hypoxia in triggering these Hb and Hct elevations. After horizontal rest for 20 min, 10 volunteers performed 3 maximal apneas spaced by 2 min, each preceded by a deep inspiration of air. The series was repeated using the same apneic durations but after 1 min of 100% oxygen (O(2)) breathing and O(2) inspiration prior to each apnea. Mean apneic durations were 150, 171, and 214 s for apneas 1, 2, and 3, respectively. Relative to pre-apnea values, the mean post-apneic arterial O(2) saturation nadir was 84.7% after the air trial and 98% after the O(2) trial. A more pronounced elevation of both Hb and Hct occurred during the air trial: after apnea 1 with air, mean Hb had increased by 1.5% (P < 0.01), but no clear increase was found after the first apnea with O(2). After the third apnea with air Hb had increased by 3.0% (P < 0.01), and with O(2) by 2.0% (P < 0.01). After the first apnea with air Hct had increased by 1.9% (P < 0.01) and after 3 apneas by 3.0% (P < 0.01), but Hct did not change significantly in the O(2) trial. In both trials, Hb and Hct were at pre-apneic levels 10 min after apneas. Diving bradycardia during apnea was the same in both trials. We conclude that hypoxia contributes to spleen contraction during apnea, likely through chemosensor-related sympathetic output. There are, however other factors involved that trigger spleen contraction even in the absence of hypoxia.

Size matters: spleen and lung volumes predict performance in human apneic divers.

Humans share with seals the ability to contract the spleen and increase circulating hematocrit, which may improve apneic performance by enhancing gas storage. Seals have large spleens and while human spleen size is small in comparison, it shows great individual variation. Unlike many marine mammals, human divers rely to a great extent on lung oxygen stores, but the impact of lung volume on competitive apnea performance has never been determined. We studied if spleen- and lung size correlated with performance in elite apnea divers. Volunteers were 14 male apnea world championship participants, with a mean (SE) of 5.8 (1.2) years of previous apnea training. Spleen volume was calculated from spleen length, width, and thickness measured via ultrasound during rest, and vital capacity via spirometry. Accumulated competition scores from dives of maximal depth, time, and distance were compared to anthropometric measurements and training data. Mean (SE) diving performance was 75 (4) m for constant weight depth, 5 min 53 (39) s for static apnea and 139 (13) m for dynamic apnea distance. Subjects' mean height was 184 (2) cm, weight 82 (3) kg, vital capacity (VC) 7.3 (0.3) L and spleen volume 336 (32) mL. Spleen volume did not correlate with subject height or weight, but was positively correlated with competition score (r = 0.57; P < 0.05). Total competition score was also positively correlated with VC (r = 0.54; P < 0.05). The three highest scoring divers had the greatest spleen volumes, averaging 538 (53) mL, while the three lowest-scoring divers had a volume of 270 (71) mL (P < 0.01). VC was also greater in the high-scorers, at 7.9 (0.36) L as compared to 6.7 (0.19) L in the low scorers (P < 0.01). Spleen volume was reduced to half after 2 min of apnea in the highest scoring divers, and the estimated resting apnea time gain from the difference between high and low scorers was 15 s for spleen volume and 60 s for VC. We conclude that both spleen- and lung volume predict apnea performance in elite divers.

Effect of hypercapnia on spleen-related haemoglobin increase during apnea.

BACKGROUND: Splenic contraction associated with apnea causes increased haemoglobin concentration and haematocrit (Hct), an effect that may promote prolonged breath-holding. Hypoxia has been shown to augment this effect, but hypercapnic influences have not been investigated previously. METHODS: Eight non-divers performed three series of apneas on separate days after inspiration of oxygen with different carbon dioxide (CO2) levels. Each series consisted of three apneas 2 minutes apart: one with pre-breathing of 5% CO2 in oxygen (O2, 'Hypercapnia'); one with pre-breathing of 100% O2 ('Normocapnia'); and one with hyperventilation of 100% O2 ('Hypocapnia'). The apnea durations were repeated identically in all trials, determined from the maximum duration attained in the CO2 trial. A fourth trial, breathing 5% CO2 in O2 for the same duration as these apneas was also performed ('Eupneic hypercapnia'). In three subjects, spleen size was measured using ultrasonic imaging. RESULTS: Haemoglobin increased by 4% after apneas in the 'Hypercapnia' trial (P = 0.002) and by 3% in the 'Normocapnia' trial (P = 0.011), while the 'Hypocapnia' and 'Eupneic hypercapnia' trials showed no changes. The 'easy' phase of apnea, i.e., the period without involuntary breathing movements, was longest in the 'Hypocapnia' trial and shortest in the 'Hypercapnia' trial. A decrease in spleen size was evident in the hypercapnic trial, whereas in the hypocapnia trial spleen size increased, while only minor changes occurred in the other trials. No differences were observed between trials in the cardiovascular diving response. CONCLUSION: There appears to be a dose-response effect of CO2 on triggering splenic contraction during apnea in the absence of hypoxia.