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Procedural tools and pension reform in the long run: the case of Sweden
Welfare state reform is understood to be risky, difficult and still ongoing. As such, there is a need for analytic tools that can aid understanding of how governments are able to overcome the various barriers they face in seeking change, and the challenges of managing complex and hybridised welfare arrangements. This article argues that the policy tools literature provides several promising avenues for doing so. Specifically, it suggests that procedural policy tools - increasingly recognised in policy studies - are often critical for mitigating risk of blame, sustaining coalitions and supporting the ongoing adaptation of social policy systems to changing conditions and information. This is especially critical where policy innovations entail new substantive relationships between states, citizens and markets, as initial assumptions about individual and group behaviour are likely to be flawed. Procedural tools can enable learning and recalibration in the pursuit of public legitimacy for changing arrangements. To demonstrate the argument, this article engages closely with a case study of public pension reform in Sweden in the 1990s. The case study finds that, initially, reformers made use of a politically insulated parliamentary working group to design a new system, one which attempted to automate elements of policymaking and transfer risk from the state to the individual. However, this goal has proved more difficult to realise than imagined, and in the longer-term, the government used procedural tools for the purposes of learning and recalibration, and in doing so has gone some way to re-establishing modified forms of state accountability.
Journal Article
Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates
Background: Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion – the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle. Methods: To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents. Results: The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers. Conclusion: In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.
Journal Article
What happens at two? Immunisation stakeholders’ perspectives on factors influencing sub-optimal childhood vaccine uptake for toddlers in regional and remote Western Australia
Background
In Western Australia (WA), children aged 24 months living regionally or remotely (non-urban) have suboptimal vaccine uptake. As there has not yet been a systematic approach to understanding the facilitators and barriers to childhood vaccination in regional and remote WA, this study aimed to understand the views of key immunisation stakeholders regarding barriers and solutions.
Methods
Drawing on the World Health Organization’s “Tailoring Immunization Programmes” approach, we undertook a qualitative study with three forms of data collection: (1) semi-structured interviews with immunisation experts within Australia’s immunisation system, (2) a semi-structured focus group with immunisation coordinators and health workers working in regional or remote WA, and (3) member checking with senior staff from WA Health. Data from the interviews and focus group was deductively analysed using the Capability-Opportunity-Motivation-Behaviour (COM-B) model on NVivo 20.
Results
There was no clear consensus on the typical under-vaccinated child in country WA. A range of barriers were identified: lack of awareness of the vaccine schedule, difficult access to vaccination services, a shortage in a workforce able to have meaningful conversations with vaccine hesitant parents, ineffective reminder systems, and the rapid spread of misinformation. Participants described previous efforts used to improve vaccine uptake, and felt the following would improve uptake: better access to vaccine clinics, building capacity of Aboriginal Health Workers, and vaccine reminders.
Conclusion
This is the first time the facilitators and barriers to routine childhood vaccine uptake in country WA has been explored. Addressing some of these barriers may see an increase in uptake.
Journal Article
Coagulation Biomarkers and Mortality in Severe COVID-19: The Prognostic Value of Factor XIII Decline and Elevated D-Dimers
Introduction
This study investigated the roles of d-dimers, fibrinogen, activated partial thromboplastin time (aPTT), and Factor XIII (FXIII) in critically ill COVID-19 patients.
Methods
68 patients were included into the study based on the inclusion criteria. Severe illness was defined as COVID-19 pneumonia leading to acute respiratory failure requiring mechanical ventilation and ICU (Intensive Care Unit) care. Patients who received Extracorporeal Membrane Oxygenation therapy were excluded due to its effects on the coagulation system. Blood samples were collected on day one and days five to seven, to measure coagulation parameters (aPTT, d-dimer, fibrinogen, and FXIII).
Results
In total, 59% of the patients died during their hospital stay. Coagulation parameters showed elevated d-dimer levels in 95.6% of patients, while FXIII activity significantly decreased during the first week in ICU. A drop in FXIII activity over the first week (FXIII Δ) emerged as a significant predictor of in-hospital mortality (HR = 2.174, P = .031), while d-dimers did not. No significant changes in aPTT, fibrinogen, or d-dimer levels were observed between days one and five to seven.
Conclusion
The change in Factor XIII activity during the first week in ICU (FXIII Δ) emerged as an independent predictor of in-hospital mortality. D-dimer levels were elevated in nearly all patients, but did not serve as an independent predictor of in-hospital mortality, possibly due to the homogeneity of the cohort. Overall, the results emphasize the importance of monitoring d-dimers and Factor XIII in predicting disease severity and outcomes in COVID-19 patients.
Journal Article
Cardiometabolic risk factors in the Swedish Werlabs cohort based on self-initiated health screening: cohort profile
PurposeThere is limited research on individuals undergoing self-initiated health examinations, and the Werlabs cohort will be a base for such research.ParticipantsAll individuals aged 18 or older who had undertaken a self-initiated health examination at Werlabs AB with at least one recorded value of creatinine or cholesterol in Sweden (from 1 January 2015 through 31 December 2023) was included. Medical history and anthropometric measurements were self-reported through an online questionnaire. We describe cohort baseline characteristics, demographic variables and cardiometabolic risk factors.Findings to dateThe study population includes 149 556 individuals who provided at least one health screening. The median (IQR) age was 43 (33–54) years and 54% were women. The most common self-reported chronic disease was hypertension (4.5%), followed by cardiovascular disease (0.9%) and 12.6% reported values of obesity. The prevalence was 2.1% for diabetes, 1.2% for kidney disease (including an estimated glomerular filtration rate of <60 mL/min/1.73 m2), 57.8% for a low-density lipoprotein cholesterol level of >3.0 mmol/L and 4.1% for anaemia (haemoglobin <120 g/L and <130 g/L for women and men, respectively). Interestingly, 1.5% of the individuals had a glucose measurement of >7.0 mmol/L, without reporting a previous diagnosis of diabetes. In an analysis restricted to 621 individuals with recorded blood pressure data between the age of 40 and 70 years and without existing cardiovascular disease, diabetes or kidney disease, 35,4% were classified as high or very high cardiovascular risk according to the 2021 ESC guidelines on cardiovascular disease prevention and with lipid levels that made them eligible for lipid-lowering therapy.Future plansThe Werlabs cohort comprises a rather healthy and young population that can provide opportunities for future studies on individuals undergoing self-initiated health examinations and has the potential to impact treatment of cardiometabolic risk factors.
Journal Article
High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study
Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS).
We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used.
In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature.
The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.
Journal Article
Cardiopulmonary resuscitation in veno-venous-ECMO patients—A retrospective study on incidence, causes and outcome
Cardiac arrest in a modern intensive care unit (ICU) is associated with poor outcome although optimal resources are present at all times. Data on cardiac arrest (CA) of the increasing cohort of patients with veno-venous-extracorporeal membrane oxygenation (VV-ECMO) are not available. Due to the highly invasive nature of this procedure, other incidences and causes of cardiac arrest are expected when compared to the ICU population without ECMO. This study focuses on cardiac arrest under VV-ECMO treatment.
Retrospective single-center observational study including all VV-ECMO patients from 1st January 2019 until 31st March 2022. Primary focus of this study was number and causes for CA during VV-ECMO treatment. Secondary endpoints were treatment procedure, complications and outcome.
140 patients were treated with VV-ECMO in the study period. Of those, 23 patients had 29 CA with need for cardiopulmonary resuscitation (CPR) during VV-ECMO treatment. Nearly half of all CA (48%; n = 14) occurred during medical procedures and 21% (n = 6) were device related. Pulseless electric activity (PEA) was the most common rhythm upon CPR initiation (72%). ROSC was achieved in 86%, two CA (6.9%) resulted in extracorporeal CPR. Survival to hospital discharge was 13% following CPR.
CA occurs in over 15% of all patients treated with a VV-ECMO. Medical procedures during VV-ECMO are associated with a high risk of CA and should be planned with care. Also, the rate of ROSC was very high, only a small number of patients survived the overall VV-ECMO treatment course.
Journal Article
Dependence of the Abundance of Reed Glass-Winged Cicadas (Pentastiridius leporinus (Linnaeus, 1761)) on Weather and Climate in the Upper Rhine Valley, Southwest Germany
The planthopper Pentastiridius leporinus, commonly called reed glass-winged cicada, transmits the pathogens “Candidatus Arsenophonus phytopathogenicus” and “Candidatus Phytoplasma solani”, which are infesting sugar beet and, most recently, also potato in the Upper Rhine valley area of Germany. They cause the “Syndrome Basses Richesses” associated with reduced yield and sugar content in sugar beet, leading to substantial monetary losses to farmers in the region. No effective solutions exist currently. This study uses statistical models to understand to what extent the abundance of cicadas depends on climate regions during the vegetation period (April–October). We further investigated what influence temperature and precipitation have on the abundance of the cicadas in sugar beet fields. Furthermore, we investigated the possible impacts of future climate on cicada abundance. Also, 22 °C and 8 mm/day were found to be the optimal temperature and precipitation conditions for peak male cicada flight activity, while 28 °C and 8 mm/day were the optimum for females. By the end of the 21st century, daily male cicada abundance is projected to increase significantly under the worst-case high greenhouse gas emission scenario RCP8.5 (RCP-Representative Concentration Pathways), with confidence intervals suggesting a possible 5–15-fold increase compared to current levels. In contrast, under the low-emission scenario RCP2.6, male cicada populations are projected to be 60–70% lower than RCP8.5. An understanding of the influence of changing temperature and precipitation conditions is crucial for predicting the spread of this pest to different regions of Germany and other European countries.
Journal Article
Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial
Background
Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required.
Methods
We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring.
Results
We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min;
p
< 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min;
p
< 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min;
p
< 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes
p
= 0.36.
Conclusions
Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population.
Trial registration
: Clinical trials registration (NCT04958668) was completed on 1 July 2021.
Journal Article